jnosis  and  Treatment 
of  Haemorrhoids. 


By  Chas.  B.  Kelsey,  M.  D 


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THE 


Diagnosis  a^d  Treatmen/ of  H/Emorrhoids, 


WITH  GENERAL  RULES  AS  TO  THE 


EXAMINATION    OF    RECTAL    DISEASES. 


CHAS.  B.   KELSEY,    M.   D., 

Surgeofi  to  St.  Paurs  Injirma)-y  for  Diseases  of  the  Rectwn;  Con- 
sulting Surgeo7i  for  Diseases  of  t lie  Rectum  to  the  Harlejn 
Hospital  and  Dispensary  for  Women  and  Children . 

NEW   YORK. 


1887. 
GEORGE  S.   DAVIS, 

OSTROIT,    MICH 


Copyrighted  by 
GEORGE  S.   DAVIS. 


TABLE  OF  CONTENTS. 


Page. 

Chapter     I.     General    Rules   for  Examination  and  Diag- 
nosis    ^ 

II.     Varieties  of  Hemorrhoids 20 

III.  Treatment 3° 

IV.  Ligature 4i 

V.     Injections 45 

VI.     Clamp 65 


ILLUSTRATIONS. 


Page. 

Fig.   I.  Electric  Illuminator 9 

2.  Internal  Hemorrhoids  with  Eversion ii 

3.  Author's  Rectal  Retractor 17 

4.  External  Venous  Hemorrhoids 21 

5.  External  Cutaneous  Hemorrhoids 23 

7.  Syringe  for  Carbolic  Acid 48 

8.  Pile  Forceps 65 

9.  Author's  Clamp 66 

10.  Smith's  Clamp 66 

11.  Paquelin  Cautery 68 


PIlJ]rACE. 


Concerning  this  little  book  it  is  only  necessary  t©  say 
that  it  contains  the  results  of  my  own  experience  with  the 
various  methods  of  curing  hemorrhoids  up  to  the  present 
time.  It  is  written  solely  for  my  fellow  practitioners,  and 
with  the  wish  that  they  may  find  it  a  safe  guide  in  practice. 
In  it  many  of  the  questions  which  are  constantly  asked  as 
to  the  value  of  different  operations  will  be  answered  as  far  as 
I  am  able  to  do  so. 

CHAS.   B.   KELSEY. 
No.  25  Madison  Ave.,  New  York. 


CHAPTER  I. 

EXAMINATION  AND  DIAGNOSIS. 

Generally,  to  one  unaccustomed  to  the  ex- 
amination of  patients  suffering  with  disease  of 
the  lower  bowel,  the  diagnosis  is  surrounded  by  many 
purely  imaginary  difficulties.  This  is  shown  by  the 
fact  that  the  first  inquiry  of  almost  all  such  practition- 
ers is  "  What  speculum  do  you  use  ? "  as  though  there 
must  be  some  mechanical  contrivance  by  which  the 
senses  of  touch  and  vision  can  be  so  improved  upon 
as  to  render  the  discovery  of  obscure  troubles  much 
simpler  than  it  otherwise  would  be. 

The  same  idea  is  well  fixed  in  the  minds  of 
patients  who,  under  the  false  idea  that  an  examination 
and  diagnosis  necessarily  mean  a  painful  use  of  instru- 
ments, will  defer  treatment  until  disease  has  made 
irreparable  progress.  The  surprise  of  such  patients 
when  a  diagnosis  is  made  by  mere  sight,  or  at  most 
by  a  painless  digital  examination,  is  only  equalled  by 
that  of  the  young  practitioner  when  he  is  told  that 
only  in  exceptional  cases  is  it  necessary  to  use  any 
instrument  whatever. 

The  secret  of  successful  diagnosis  of  these  dis- 
eases consists  in  taking  nothing  for  granted.  Every 
affection  of  the  lower  four  inches  of  the  bowel  can  be 
both  seen  and  felt  if  the  practitioner  will  only  take  the 
necessary  trouble  to  go  about  it    in  the   proper  way; 


and  a  disease  which  can  be  felt  and  looked  at  is  gen- 
erally eas)-  of  diagnosis.  The  man  who  fails  to  detect 
the  nature  of  a  rectal  trouble  is  generally  the  one  who 
has  refused  to  employ  the  necessary  and  yet  simple 
methods  bv  which  alone  a  diagnosis  can  be  reached  ; 
and  the  man  who  acquires  a  reputation  as  a  diagnos- 
tician in  this  department  is  the  one  who  simply  uses 
his  eyes  and  his  fingers,  and  refuses  to  deceive  him- 
>elf  by  jumping  at  conclusions  in  the  dark. 

To  one  in  the  daily  practice  of  any  department 
of  surgery  a  routine  practice  soon  recommends  itself 
as  most  likely  to  eliminate  errors  and  lead  to  a  correct 
conclusion  ;  and  the  following  is  the  one  which  has 
been  adopted  by  myself,  and  one  to  which  every 
patient  great  or  small,  male  or  female,  submits. 

The  patient's  name,  age,  condition  in  life,  etc., 
are  first  entered  in  a  case  book.  Next  he  or  she  is 
urged  to  tell  the  story  of  the  disease  in  all  its  details, 
and  this  story  is  never  interrupted  or  cut  short  ;  for  in 
the  nervousness  of  a  first  visit,  often  made  at  great 
expense  of  time  and  trouble,  and  with  the  fear  of  a 
painful  examination  before  their  minds,  a  nervous 
patient  will  often  begin  the  history  of  his  sufferings 
backward,  and  if  allowed  to  recover  himself  by  a  few 
sympathetic  words  will  not  infrequently  give  the  gist 
of  the  whole  matter  at  the  very  end.  This  takes  time, 
but  time  is  never  of  any  moment  until  the  diagnosis 
has  been  made.  It  is  often  necessary  to  devote  an 
hour  or  more  to  the  first  examination  of  a  patient,  but 


—  3  — 

no  patient  should  be  allowed  to  end  his  first  visit  un- 
til a  diagnosis  has  been  made  or  the  surgeon  acknow- 
ledges to  himself  his  inability  to  make  such  diagnosis. 

By  the  time  the  patient  has  told  the  story  the  sur- 
geon should  be  in  the  possession  of  certain  informa- 
tion, and  if  not  he  must  proceed  by  a  few  direct  ques- 
tions to  try  and  obtain  it.  What  he  must  know  is  this. 
How  long  has  the  patient  been  sick  ?  Is  there  any 
pain,  if  so  of  what  character,  and  is  it  in  any  way 
dependent  upon  the  evacuation  of  the  bowels  ?  Is 
there  any  protrusion  of  the  bowels  at  stool,  and  if  so 
what  is  its  character,  and  does  it  return  spontaneously 
or  is  it  necessary  to  replace  it  ?  Are  the  bowels  regu- 
lar or  is  there  diarrhoea,  and  of  what  character  ?  Is 
there  any  bleeding  ?  In  addition  it  must  be  discovered 
whether  there  has  been  emaciation,  febrile  action,  and 
discharge  of  any  sort. 

From  such  a  verbal  examination  much  may  be 
gained.  In  fact  the  positive  diagnosis  can  sometimes 
be  made.  But,  on  the  other  hand,  it  is  astonishing 
how  often  the  most  intelligent  patient  will  utterly 
mislead  the  examiner ;  and  though  I  have  great  confi- 
dence in  this  indispensable  history  as  a  prelude  to 
actual  examination,  considerable  experience  has 
taught  me  never  to  trust  to  it  alone,  for  the  simple 
reason  that  although  it  may  convey  all  the  informa- 
tion necessary,  the  surgeon  is  never  sure  that  he  is  not 
being  unwittingly  led  upon  a  false  track  by  the  most 
intelligent  answers  his  patient  is  able  to  give. 


For  example  :  A  gentleman  whose  medical  fame 
has  extended  wherever  medical  literature  is  read, 
came  to  me  some  time  since  for  "  piles  which  had 
troubled  him  ever  since  he  could  remember."  He 
was  sure  he  had  them  when  seven  or  eight  years  old, 
and  an  examination  showed  three  very  large  fibroid 
polypi.  Another  told  me  he  suffered  only  from 
severe  pain  at  defecation,  but  asserted  that  "there 
never  was  any  tumor  to  speak  of."  Of  course  I  ex- 
amined him  for  fissure,  but  none  existed.  Then  after 
an  enema,  he  again  placed  himself  on  the  table  and 
showed  a  cluster  of  well-developed  internal  hemor- 
rhoids, tightly  constricted  by  the  sphincter. 

A  patient  with  the  strongest  motive  for  conveying 
all  the  information  in  her  power,  is  often  unable  to  do 
so  except  in  language  which  though  perfectly  true,  will 
convey  an  entirely  different  idea  to  the  physician  from 
the  correct  one.  I  have  just  returned  from  the  bed- 
side of  a  lady  upon  whom  I  operated  a  few  days  ago 
for  a  laceration  of  the  neck  of  the  womb  and  large 
hemorrhoids.  Her  nurse  informed  me  yesterday  with 
an  air  of  great  wisdom  that  the  whole  bowel  came 
down  for  an  inch  or  more,  all  around,  whenever  she 
had  a  passage,  and  the  patient  had  already  told  her 
lady  friends  that  she  was  quite  sure  the  operation  was 
a  failure.  The  most  careful  questioning  of  both 
patient  and  nurse  brought  out  the  facts  that  every 
time  the  bowels  had  moved  since  the  operation  there 
had  been  a  protrusion  ;  that  this  tumor  was  fully  an 


—  5  — 
inch  in  length  ;  that  it  completely  surrounded  the  anus 
and  went  back  spotaneously  with  more  or  less  pain. 
Failing  to  weaken  this  testimony  by  any  cross-ques- 
tioning, I  had  about  made  up  my  mind  that  the  patient 
was  suffering  from  an  invagination  and  asked  for  an 
examination.  She  was  placed  on  the  commode,  the 
protrusion  was  pressed  down,  she  moved  gently  back 
into  bed  and  I  was  called  from  the  next  room,  but  the 
tumor  had  disappeared.  It  had,  however,  been  "fully 
.  an  inch  long,"  as  usual.  Another  attempt  was  made 
and  the  tumor  was  again  brought  down  in  the  same 
way,  and  this  time  I  saw  it  in  its  enormity.  It  con- 
sisted of  a  slight  eversion  of  the  muco-cutaneous  junc- 
tion of  the  anus — the  pedicles  of  the  very  large  hemor- 
rhoidal tumors  I  had  removed.  In  this  case  the  anus 
was  very  patulous,  the  patient  of  very  slight  muscular 
power  and  of  relaxed  fibre,  and  at  the  operation  it  had 
been  a  question  as  to  how  much  of  the  muco-cutane- 
ous tissue  to  remove.  Enough  was  taken  off  to  cure 
the  patient  but  not  enough  to  cause  a  subsequent 
stricture,  and  when  the  swelling  subsides  she  will  be 
perfectly  satisfied,  and  there  will  be  no  eversion. 

This  is  but  an  example  of  how  little  positive  infor- 
mation many  patients  are  able  to  give  their  physicians 
as  to  their  own  condition.  A  prolapse  two  or  three 
inches  long  and  a  simple  pruritus  will  both  be  de- 
scribed as  piles. 

After  this  line  of  investigation  has  been  exhausted 
the  inevitable  examination  by  touch  and  vision  follows. 


General  practitioners  tell  me  they  have  difficulty 
in  obtaining  the  consent  of  patients  to  an  examination. 
I  never  have  had,  save  once.  That  case  was  a  for- 
eigner who  told  me  when  I  proposed  it  that  he  '^  had 
entirely  too  great  a  respect  for  me  to  allow  me  to  do 
such  a  thing."  My  only  answer  was  that  1  had  too 
great  a  respect  for  myself  to  treat  him  without  know- 
ing what  was  the  matter,  and  we  parted  amicably. 

And  yet  an  examination  to  a  lady  is  not  a  pleasant 
thing.  It  is  in  fact  a  thing  which  will  cause  her  to 
suffer  silently  for  many  years  rather  than  submit  to  it. 
It  is  only  when  suffering  has  forced  her  to  it  that  she 
will  submit,  but  that  point  has  always  been  reached 
when  she  consents  to  consult  a  sugeon  or  a  specialist 
for  treatment.  Then  she  expects  to  be  examined  (in 
fact  has  very  little  respect  for  the  surgeon  if  he  does 
not  examine),  and  it  remains  for  him  to  make  the  un- 
avoidable examination  in  the  way  least  offensive  to  his 
patient. 

For  this  purpose  a  trained  female  attendant  should 
always  be  in  waiting.  After  the  history  has  been  taken 
and  the  physician  has  in  a  measure  gained  the  confi- 
dence of  his  patient,  she  is  handed  over  to  the  nurse 
in  waiting,  who  gives  the  enema,  arranges  the  patient 
on  the  chair,  covers  her  with  a  sheet,  and  when  all  is 
ready,  signs  to  the  doctor.  His  work  may  be  done  at 
a  single  glance,  or  may  require  careful  investigation 
and  examination  with  finger  or  instruments;  but  when 
it  is  done  the  patient  is  again  given  over  to  the  nurse, 


—  7  — 

and  when  she  is  once  more  herself,  the  diagnosis  is 
made  and  the  question  of  treatment  may  for  the  first 
time  be  entered  upon. 

I  do  not  know  that  it  is  necessary  to  dilate  upon 
this  point  any  further,  except  to  say  that  I  have  found 
it  best  in  my  own  practice  to  have  two  entirely  separ- 
ate waiting-rooms,  one  for  ladies  and  the  other  for 
gentlemen.  It  is  pretty  well  known  that  all  patients 
who  come  to  me  have  rectal  disease,  and  ladies  do  not 
care  to  take  their  turn  in  the  presence  of  several  gen- 
tlemen, I  have  also  a  special  apparatus  for  the  ad- 
ministration of  enemata,  and  in  immediate  connection 
with  the  examining-room  there  should  always  be  a  re- 
tiring-room and  water-closet.  This  is  absolutely  in- 
dispensable, both  for  decent  privacy  of  the  patient  and 
for  thorough  examination. 

The  enema  may  be  given  in  any  way  most  con- 
venient, but  often  requires  great  gentleness  on  the 
part  of  the  giver.  For  my  own  use  I  have  rather  an 
elaborate  apparatus,  consisting  of  a  glass  jar  holding- 
one  gallon,  which  stands  upon  a  shelf  seven  feet  above 
the  floor,  and  is  filled  by  a  rubber  tube  connecting 
with  what  is  popularly  known  as  a  barber's  faucet,  by 
which  either  hot  or  cold  water  can  be  drawn  from  the 
same  tube  at  pleasure.  This,  how^ever,  is  useful  for 
several  other  purposes  besides  the  administration  of 
an  ordinary  enema. 

A  small,  smooth,  glass  tube  may  often  be  intro- 
duced with  less  pain  than   the   usual   metal   tip  of   tht- 


—   8  — 

Davidson's  syringe;  and  a  small,  soft  rubber  catheter 
answers  an  equally  good  purpose,  but  whatever  in- 
strument is  used,  should  be  either  in  the  hands  of  the 
surgeon  or  of  an  intelligent  nurse. 

The  examination  may  be  made  on  any  ordinary 
operating  table,  or  on  a  more  elaborate  gynaecological 
chair,  as  the  operator  prefers.  Since,  however,  there 
is  a  good  deal  of  gynaecological  work  to  be  done  in 
connection  with  this  specialty,  the  patient  should  be 
enabled  to  assume  Sims's  position  with  ease.  For 
a  rectal  examination  alone,  in  male  or  female,  the 
left  lateral  position  is  the  best,  and  the  correct  Sims's 
position  is  not  necessary.  Either  natural  or  artifical 
light  may  be  used.  For  many  cases  there  is  little 
choice  between  the  two,  but  for  illumination  within  the 
rectal  pouch  artifical  light  has  the  advantage.  For 
this  reason  I  have  long  been  in  the  habit  of  using  a 
large  and  powerful  lamp  and  lens,  such  as  is  used  for 
laryngological  examinations,  and  is  figured  in  my  work 
on  Diseases  of  the  Rectum.* 

The  small  incandescent  electric  lights  to  be  intro- 
duced into  the  bowel  are  of  little  use  for  ordinary  ex- 
aminations, because  without  ether  and  stretching  of 
the  sphincter,  the  lamp  and  speculum  fill  up  the  entire 
space  and  nothing  can  be  .seen,  but  under  favorable 
conditions  with  a  widely-dilated  anus  they  may  be  of 
^reat  practical  advantage. 

*  Diseases  of  the  Rectum,  N.  Y.,  Wm.  Wood  &  Co.,  1884, 
p.  63. 


A  better  form  of  electric  light  is  that  manufactured 
by  the  "  U.  S.  Electrical  Co.,"  and  shown  in  the  cut. 
It  can  only,  be  used  with  a  storage  battery,  but  it 
has  this  advantage,  that  it  is  portable,  and  is  never 
obstructed  by  the  head  of  the  operator  in  his  motions 
to  obtain  a  good  view. 


Fig.  t. 


Suppose  now  that  an  enema  has  been  given,  the 
patient  has  strained  down  the  protrusion  which  ordi- 
narily takes  place,  and  while  it  is  down  has  taken  the 
place  upon  the  examining  table  in  a  good  light. 

If  any  protrusion  at  all  be  visible  it  will  be  one  of 
the  following  things: 

1.  External  hemorrhoids. 

2.  Internal  hemorrhoids  which  have  been  brought 
to  light. 

3.  Prolapsus. 


lO     

4.  Polypus. 

5.  Cancer. 

As  the  patient  is  never  able  by  a  verbal  descrip- 
tion to  enable  the  surgeon  to  decide  which  of  these  he 
is  to  treat,  the  necessity  of  this  examination  and  the 
folly  of  dispensing  with  it  become  self-evident. 

I'he  various  forms  of  external  hemorrhoids  will 
be  described  in  the  next  chapter. 

Where  internal  hemorrhoids  are  to  be  distinguished 
from  other  protruding  tumors,  I  hardly  know  how  to 
convey  in  words  what  is  so  perfectly  evident  to  the 
eyes  when  one  has  seen,  if  only  for  a  single  time,  the 
different  varieties  of  tumors.  The  diagnosis  is  gen- 
erally between  hemorrhoids  and  prolapse,  and  where 
the  two  conditions  are  typical  they  are  easily  distin- 
guished. An  hemorrhoid  is  a  distinct,  varicose  new 
growth.  It  springs  from  a  part  of  the  circumference 
of  the  rectum  or  anus,  and  when  it  protrudes  it  gen- 
erally drags  down  the  margin  of  the  anus  to  which  it  is 
attached.  When  several  hemorrhoids  protrude  several 
different  points  of  the  anal  circumference  are  involved, 
and  the  tumors  all  meet  in  the  centre,  some  larger  and 
some  smaller,  like  a  bunch  of  large  and  small  grapes, 
but  all  trying  to  get  out  of  the  anus  at  the  same  point 
and  filling  up  the  outlet.  With  prolapsus  the  condition 
is  different.  The  bowel  is  telescoped  into  itself  from 
above,  and  what  protrudes  is  normal  gut  and  not 
a  new  formation.  The  protrusion  is  attached  evenly 
all  around;  it  is  composed  of  comparatively  healthy 


1 1 


mucous  membrane,  and  it  does  not  spring  from  the 
muco-cutaneous  verge  of  the  anus,  but  is  a  part  of  the 
rectum  proper,  and  is  therefore  covered  by  mucous 


Fig.  2. 

membrane,  and  not  by  skin  and  mucous  membrane. 
It  is  one  tumor  and  not  several;  and  yet  there  is 
a  form  of  disease  in  which  the  protrusion  is  made  up 
entirely  of  the  muco-cutaneous  verge  of  the  anus — 
swollen,  enlarged,  prolapsing  it   is   true,    but    without 


I  2 


distinct  hemorrhoidal  tumors.  The  patient  strains 
down  and  the  margin  of  the  anus  turns  out  with  skin 
on  one  side  and  mucous  membrane  on  the  other. 
The  tumors  thus  formed  are  not  properly  hemorrhoids, 
nor  do  they  constitute  a  prolapse,  though  they  will  be 
found  described  under  both  heads.  If  the  sphincter 
be  stretched  the  patient  will  be  found  to  have  large  in- 
ternal hemorrhoids  which,  by  their  mechanical  effects, 
have  loosened  the  cellular  tissue  at  the  verge  of  the 
anus.  The  condition  to  which  I  refer  is  well  shown  in 
Fig.  2,  in  which  the  part  marked  i,  is  covered  by 
mucous  membrane,  and  the  others  by  skin.  And 
this  condition  may  sometimes  lead  the  t)perator  to 
wonder  in  his  own  mind  whether  he  is  operating  for 
hemorrhoids  or  prolapse  ;  but  since  the  operation  is 
the  same  in  both  cases,  and  invariably  cures  the 
patient,  there  is  not  much  in  the  name. 

Internal  hemorrhoids  are  distinguished  from  polypi 
both  by  the  appearance  of  the  tumors  themselves  and 
by  their  attachment.  In  the  former  the  base  is  the 
largest  part  of  the  tumor.  In  the  latter  the  tumor 
is  attached  to  the  wall  of  the  rectum  by  a  distinct 
pedicle  often  very  long  and  delicate.  To  the  practised 
eye  the  appearance  of  the  presenting  tumor  is  suffi- 
cient for  a  diagnosis,  but  the  difference  between  the 
two  though  easily  appreciated  by  sight  is  difficult  to 
express  in  words.  The  polypus  is  generally  harder, 
firmer,  and  contains  more  connective  tissue.  It  is  also 
apt  to  be  mamellated  like  a  mulberry,  while  the  mucous 


_    13   — 

membrane  covering  a  hemorrhoid  is  tightly  stretched 
and  even.  The  pedicle,  of  larger  or  smaller  size,  is. 
however,  the  diagnostic  point.  A  tumor  the  size  of 
an  egg,  attached  by  a  stalk  the  size  of  a  lead  pencil 
has  little  resemblance  to  a  hemorrhoid. 

Between  polypus  and  prolapse  the  diagnosis  is  easy 
with  care,  and  yet  within  a  short  time  physicians  of 
skill  have  sent  me  cases  in  which  there  had  been  pal- 
palable  error.  The  first  was  a  polypus,  said  to  be  a 
prolapse,  in  which  no  examination  had  ever  been 
made.  The  second  was  a  prolapse,  said  to  be  a  poly- 
pus and  which  really  looked  very  much  like  one,  but 
in  reality  was  a  protrusion  of  a  small  lateral  section  of 
the  bowel,  involving  only  a  small  part  of  its  circum- 
ference. 

Between  a  cancer  and  hemorrhoids  a  mistake  can 
hardly  be  made  when  once  the  tumors  are  seen,  though 
the  history  and  symptoms  may  be  exactly  identical. 
A  lady  visited  me  from  Albany  some  time  since  giving 
the  ordinary  history  of  painful  and  bloody  passages 
with  a  tumor  that  protruded  at  stool  but  went  back 
spontaneously  or  with  slight  pressure.  On  examining 
this  tumor,  which  I  supposed  to  be  hemorrhoidal,  I 
found  an  epithelioma  protruding  from  the  anus,  which 
involved  the  entire  circumference  of  the  bowel,  but 
began  two  inches  above  the  external  sphincter  and  ex- 
tended from  this  point  for  a  couple  of  inches  upward. 
It  was  this  tumor  which  acted  like  a  foreign  body  and 
was  expressed  in  each  act  of  defecation. 


—    14  — 

Again,  I  have  seen  old  cases  of  protruding  and 
irreducible  hemorrhoids  which  have  been  out  of  the 
body  for  years,  so  ulcerated,  eroded,  and  granulated 
that  they  strongly  resembled  epithelioma  of  the  anus, 
but  such  cases  are  very  rare  and  the  distinction  can 
certainly  be  made  by  careful  observation. 

Suppose  now  that  the  patient  has  described  a 
distinct  protrusion  at  stool,  but  when  the  enema  has 
been  given,  and  the  surgeon  comes  to  examine,  no 
such  protrusion  is  visible,  or  can  not  be  brought  into 
view  by  any  effort  of  the  patient.  It  has  simply  "  gone 
back."  Under  these  circumstances  I  cannot  too 
highly  recommend  an  examination  with  the  finger 
while  the  patient  is  straining  in  the  ordinary  position  of 
defecation.  Under  these  circumstances  the  expulsive 
effort  has  the  greatest  possible  effect, -and  a. slight  pro- 
trusion often  becomes  perceptible  to  the  touch  which 
cannot  be  seen  with  the  patient  in  the  lateral  position 
on  a  table. 

Suppose,  again,  that  the  enema  has  been  given, 
the  patient  is  in  position,  and  there  is  no  protrusion. 
A  careful  inspection  reveals  no  opening  of  a  fistula, 
no  fissure  just  within  the  anus,  and  no  capillary  hemor- 
rhoid (to  be  described  in  the  next  chapter).  In  fact 
no  disease  is  manifest. 

The  next  step  is  a  digital  examination  of  the  rec- 
tum. The  right  index  finger  is  oiled  and  gently  intro- 
duced through  the  sphincter.  No  force  should  be 
used.     The  muscle  at   first  is  inclined  to  spasmodic 


—  15  — 
contraction,  but  this,  except  in  abnormal  states,  is 
easily  overcome  by  gentle  pressure,  and  the  finger  may 
be  introduced  its  whole  length.  In  this  way  the  last 
three  inches  and  a  half  of  the  bowel  are  brought  with- 
in the  sense  of  touch,  and  many  of  the  common  affec- 
tions may  be  diagnosticated — cancer,  stricture,  ulcer- 
ation, abscess,  fistula,  misplaced  uterus  pressing  upon 
the  bowel,  and  internal  hemorrhoids  which  are  not 
sufficiently  developed  to  protrude.  For  hemorrhoids 
of  the  usual  form  may  exist  with  all  of  the  accustomed 
symptoms  except  protrusion — hemorrhoids  of  the  in- 
ternal variety  which  are  attached  high  up,  cause  pain, 
bleeding,  and  other  symptoms,  and  yet  never  come 
down  below  the  sphincter. 

These  are  to  be  diagnosticated  by  digital  exami- 
nation. It  may  take  a  long  time  to  educate  the  finger 
up  to  the  point  of  distinguishing  these  soft  tumors 
from  the  folds  of  mucous  membrane  in  the  healthy 
bowel,  but  the  facility  must  be  acquired,  and  it  can 
only  be  done  by  constant  practice. 

Let  us  suppose  now,  once  again,  that  all  this  has 
been  done,  and  yet  the  examiner  has  discovered  no 
disease.  At  this  point  he  must  take  a  decided  respon- 
sibility, for  if  from  the  patient's  history  he  believes  that 
rectal  trouble  exists,  he  must  still  go  on  and  find  it, 
but  if  he  have  no  reason  to  believe  this,  he  may  abandon 
the  search  at  this  point  and  commit  himself  to  the 
opinion  that  there  is  no  rectal  trouble. 

If  he  decide  to  go  still  further,  there  is  but  one 


—   i6   — 

line  of  investigation  to  be  followed,  and  this  consists 
in  the  administration  of  ether,  the  dilatation  of  the 
sphincter,  and  the  use  of  the  speculum. 

It  will  be  noticed  that  up  to  this  time  the  question, 
"What  speculum  do  you  use?"  has  not  been  answered, 
and  for  the  reason  that  up  to  this  point  in  the  exami- 
nation I  use  no  speculum;  and  as  the  vast  majority  of 
examinations  will  lead  to  a  diagnosis  before  this  point 
is  reached,  it  follows  that  in  about  ninety  per  cent,  of 
all  my  rectal  cases  I  use  no  speculum  at  all. 

An  entirely  too  exalted  idea  of  the  value  of  the 
speculum  exists.  For  ordinary  examinations  it  is  un- 
necessary, and  the  diseases  which  cannot  be  detected 
by  the  routine  practice  already  described  will  not  very 
often  be  detected  by  the  simple  use  of  any  variety  of 
this  instrument.  So  strongly  has  this  experience  been 
impressed  upon  me  that  I  have  abandoned  the  use  of 
every  form  of  speculum  for  ordinary  diagnostic  purposes, 
unless  at  the  same  time  its  auxiliary  means  can  be  em- 
ployed— the  administration  of  ether.  With  ether,  a 
light,  and  a  speculum,  a  diagnosis  may  often  be  made 
which  would  otherwise  be  impossible;  but  to  use  a 
speculum,  without  ether,  for  the  purpose  of  exploring 
the  rectal  pouch,  is  merely  in  the  vast  majority  of  cases 
to  inflict  useless  suffering. 

This  does  not  apply  to  the  question  of  treatment, 
but  simply  to  diagnosis.  For  there  exists  a  certain 
class  of  diseases,  notably  circumscribed  ulcers,  which, 
when    their    situation    is    accurately   known,    can    be 


~    17    - 

brought  into  the  field  of  vision  by  a  speculum  and  thus 
treated  by  direct  applications,  but  this  is  a  very  differ- 
ent matter  from  taking  a  patient  who  complains,  per- 
haps, of  but  the  single  symptom  of  rectal  pain,  intro- 
ducing some  variety  of  speculum  by  which  only  the 
most  imperfect  view  can  be  obtained,  and  because 
nothing  is  discovered  (as  in  the  vast  majority  of  cases 
nothing  will  be),  pronouncing  the  patient  free  from 
disease. 


Fig  3. — Author's  Rectal  Retractor. 

I  cannot  make  this  ponit  any  stronger  perhaps 
than  by  adding  that  whatever  success  I  may  have 
gained  as  a  diagnostician  in  doubtful  cases  of  rectal 
disease  has  come  from  the  simple  rule  of  etherizing 
my  patient,  dilating  the  sphincter,  and  then  looking  at 
what  at  once  becomes  plainly  visible,  viz.  the  whole 
lower  five  or  six  inches  of  the  bowel.  Under  such  cir- 
cumstances, the  simpler  the  instrument  the  better.  A 
medium-sized  blade  of  Sims's  vaginal  speculum  answers 

3  A 


—    i8  — 

■every  purpose:  or  my  own  fenestrated  rectal  retractor 
which  exposes  more  surface  and  takes  up  less  room. 

It  requires  some  courage  and  self-confidence  on 
the  part  of  the  examiner  after  making  the  usual  visual 
iind  digital  examination  to  say  to  his  patient,  "All  this 
has  led  to  nothing.  I  have  no  idea  what  is  the  matter 
with  you.  Vou  must  take  ether,  if  you  wish  me  to 
find  out.'  But  this  is  the  only  proper  course,  and 
should  be  a  routine  practice  in  every  case  where  the 
svmptoms  of  rectal  disease  are  sufficiently  marked  to 
justify  it. 

From  what  has  been  said  it  must  be  evident  to 
every  reader  that  the  successful  examination  of  any 
doubtful  case  of  rectal  disease  consists  merely  in  mak- 
mg  use  of  the  ordinary  senses,  with  which  we  are  all 
provided.  There  is  no  occult  faculty  in  all  this,  no 
<kep  power  of  knowing  w^hat  is  concealed  from  the 
majority  of  mankind.  If  the  beginner  will  be  honest 
with  himself,  and  will  insist  upon  seeing  what  is  to  be 
seen,  and  feeling  what  is  to  be  felt,  he  will — except  for 
the  experience  which  only  practice  can  give — make  as 
good  a  diagnosis  in  his  first  case  as  the  specialist  who 
has  practiced  for  a  lifetime. 

I  can  add  nothing  more  to  what  has  already  been 
said  on  this  point,  except  that  the  man  who  has  fool- 
ishly allowed  himself  to  be  beguiled  into  prescribing 
some  salve  for  a  cancer,  when  he  thinks  he  is  treating 
hemorrhoids,  because  his  patient  objects  to  an  examin- 
iition,  need  not  feel  hurt  when  he  finds  himself   placed 


—  19  — 

in  a  ridiculous  light  by  some  better  man  than  himself, 
who  has  made  his  diagnosis  before  beginning  treat- 
ment. All  his  tender  regards  for  the  foolish  suscepti- 
bilities of  his  nervous  lady  patient  will  bring  him  no 
mercy  in  her  judgment.  She  is  willing  to  admit  that 
she  may  have  been  foolish,  but  she  will  make  no  al- 
lowance for  the  foolishness  of  her  physician,  and  in 
fact  he  deserves  none. 

There  are  but  three  ways  of  making  a  diagnosis — 
by  question,  by  sight,  by  touch.  The  man  who  has  ex- 
hausted these  will  seldom  fail  in  his  diagnosis,  and 
should  he  do  so,  need  not  be  ashamed.  The  man  who 
neglects  any  one  of  them  will,  sooner  or  later,  make 
some  error  which  he  might  easily  have  avoided. 


CHAPTER  II. 

THE  DIFFERENT  VARIETIES  OF.  HEMORRHOIDS 

There  are  several  perfectly  distinct  varieties  of 
hemorrhoids,  each  requiring  a  different  mode  of  treat- 
ment, and  a  treatment  which  is  applicable  to  one  may 
be  entirely  out  of  place  in  another. 

Before  discussing  various  modes  of  treatment, 
therefore,  we  must  understand  exactly  with  what  we 
are  dealing. 

A  patient  presents  himself  complaining  of  hemor- 
hoids  with  the  usual  symptoms,  and  an  examination 
shows  a  slight  swelling,  perhaps  the  size  of  the  end  of 
the  little  finger,  at  the  verge  of  the  anus.  This  small 
lound  tumor  may  have  any  one  of  three  distinct  his- 
tories: 

First. — It  may  have  formed  suddenly  in  the  course 
of  a  few  hours;  may  have  been  attended  by  consider- 
able pain,  and  may  have  immediately  driven  the  patient 
to  seek  relief.  The  patient  has  been  unusually  consti- 
pated in  the  morning,  and  may  have  strained  a  good 
deal  at  stool;  or,  he  may  have  been  up  late  on  the  pre- 
vious night,  have  drank  heavily,  smoked  a  good  deal^ 
and  lost  more  money  at  cards  than  he  could  well 
afford;  or,  without  any  of  these  palpable  causes,  he 
finds  during  the  day  that  there  is  a  sense  of  uneasiness 
at  the  anus,  and  by  examining  himself  finds  a  small, 
round,  sensitive  tumor.     At  first  he  thinks  nothing  of 


21 


it,  but  as  the  pain  increases  he  endeavors  to  push  the 
offending  swelHng  within  the  bowel,  feeHng  sure  that 
if  it  would  only  sta}^  there  he  would  find  relief.     The 


pressure  gives  temporary  relief  and  as  long  as  it  is 
continued  the  tumor  disappears,  but  the  moment  after 
it  is  removed  the  swelling  is  as  large  and  painful  as 
before.  This  usually  goes  on  all  day,  but  at  night 
when  the  sufferer  has  gone  to  bed  the   pain    is   much 


—    22    

less,  and  in  the  morning  he  is  quite  sure  that  the 
trouble  is  past.  After  a  few  hours  however,  it  is 
worse  than  ever,  and  then  if  he  be  at  all  inclined  to 
take  care  of  his  own  health  he  seeks  medical  advice. 
If,  on  the  other  hand,  the  patient  be  a  sensitive  woman, 
it  is  at  about  this  stage  of  the  disease  that  she  takes  a 
fine  cambric  needle  and  tortures  herself  by  sticking  it 
into  the  tumor.  A  drop  of  blood  and  increased  suffer- 
ing are  the  only  results. 

This  form  of  external  hemorrhoid  is  well  shown 
in  Fig.  4,  and  the  pathology  is  well  known.  One  of 
the  small  branches  of  the  external  hemorrhoidal  veins 
has  ruptured,  and  an  extravasation  has  occurred  in  the 
surrounding  cellular  tissue  just  at  the  verge  of  the 
anus.  The  pain  and  swelling  are  due  simply  to  the 
pressure  of  a  small  clot  of  blood,  which  by  a  simple 
incision  through  the  skin  may  i)e  turned  out  of  its  bed 
entire. 

Second. — Another  patient  comes  with  a  some- 
what different  history.  He  or  she  also  has  a  small 
tumor  at  the  verge  of  the  anus,  but  it  has  been  there 
for  many  months.  It  is  only  painful  at  times,  but  it  is 
always  present,  never  disappears  within  the  bowel,  and 
sometimes  causes  a  great  deal  of  suffering. 

Here  the  tumor  is  evidently  a  tag  of  skin  and  is 
hard  and  solid,  containing  no  clot  of  blood  which 
shows  by  its  dark  color  through  the  stretched  skin. 
It  may  be  red,  swollen  and  painful,  but  the  tumor  it- 
self is  more  apt  to  be  comparatively   insensitive,  while 


—  ^z  — 

just  at  its  base  a  distinct  fissure  of  the  anus  is  seea 
which  is  the  cause  of  the  pain.  This  form  of  external 
hemorrhoid  can  generally  be  traced  to  that  which  has 
just  been  described.     The  clot  has  become  organized, 


Fi. 


the  cellular  tissue  around  it  has  become  hypertrophied, 
the  skin  over  it  has  been  stretched  till  a  permanent 
growth  remains.  This  tumor  is  often  passive  for  long 
periods  of  time,  but  at  any  moment  from  a  slight  cause 
which  often  escapes  the  knowledge  of  the  patient  it 
is  liable  to  take  on  a  subacute  form  ni    inflammation. 


—    24    — 

l)ecome  red,  swollen  and  painful,  and  cause  great 
suffering. 

Third. — The  patient  presents  a  circle  of  cutaneous 
tumors  as  shown  in  Fig.  5. 

These  also  are  cutaneous  hemorrhoids  or  condyl- 
omatous  tags  as  they  are  often  called.  They  are 
merely  hypertrophies  of  the  skin  and  subjacent  con- 
nective tissue,  but  there  are  several  of  them  and  they 
are  of  large  size,  almost  completely  surrounding  the 
margin  of  the  anus.  The  adjacent  surfaces  of  these 
growths  where  they  rub  against  each  other,  and  the 
fissures  at  their  bases  between  their  points  of  attach- 
ment, are  apt  to  be  ulcerated.  These  are  also  external 
hemorrhoids,  but  they  have  been  endowed  with  a 
peculiar  significance  by  various  writers,  in  that  they 
are  supposed  to  be  proof  of  syphilitic  disease  of  the 
rectum.  1'here  is  I  believe  nothing  in  this  idea,  but 
there  can  be  no  mistake  in  the  fact  that  they  are  in- 
dicative of  serious  disease  within  the  bowel.  This 
disease  may  be  either  syphilitic  ulceration,  stricture, 
or  cancer. 

Beyond  this  point  I  have  never  been  able  to  trace 
the  pathological  significance  of  these  tumors.  They 
certainly,  when  largely  developed  as  in  the  figure,  indi- 
cate grave  disease  above  the  sphincters,  and  are  due 
generally  to  the  irritation  of  the  discharge  from  such 
disease,  but  they  are  not  diagnostic  of  the  character 
of  that  disease. 

Here,  then,  we  have  three  distinct  varieties  of  e.\- 


ternal  hemorrhoids,  and  it  must  be  perfect!}'  evident 
that  they  are  not  all  amenable  to  the  same  form  of 
treatment,  nor  are  any  of  them  to  be  treated  as  would 
be  one  of  the  bleeding  growths  just  within  the  anus, 
which  will  be  referred  to;  or  as  a  large,  prolapsing 
varicose  tumor  arising  above  the  sphincters,  and  only 
appearing  outside  the  body  as  a  result  of  straining  at 
stool. 

There  is  still  anotlier  form  of  external  hemorrhoid 
which  differs  from  any  yet  described.  In  it  there  is 
little  or  no  hypertrophy  of  the  skin  and  subcutaneous 
connective  tissue,  as  in  the  last,  nor  is  there  any  blood- 
clot  as  in  the  first,  but  when  the  patient  strains  down 
there  is  a  tumor  formed  just  at  the  verge  of  the  anus, 
and  rather  on  the  cutaneous  than  mucous  aspect.  The 
tumor  is  nothing  more  or  less  than  a  varicosity  of  an 
external  hemorrhoidal  vein,  and  the  vessel  may  often 
be  distinctly  seen  through  the  normal  and  delicate 
skin.  Such  a  tumor  is  not  painful,  and  causes  no 
symptoms  except  in  persons  of  extreme  sensitiveness, 
who  are  sometimes  very  much  worried  lest  it  should 
result  in  something  more  serious. 

All  the  forms  of  hemorrhoids  thus  far  described 
are  covered  by  skin  rather  than  mucous  membrane, 
and  all  of  them  spring  from  the  margin  of  the  anus. 
None  of  them  arise  from  within  the  sphincter  and 
come  outside,  and  none  of  them  can  be  forced  within 
the  bowel  and  made  to  remain  there.  They  are  all 
varieties  of  what  are  known  as  external  hemorrhoids, 


—     26     - 

from  their  situation,  to  distinguish  them  from  the  in- 
ternal or  those  which  develop  within  the  rectum  proper. 
This  distinction  between  external  and  internal  is  gen- 
erally very  well  drawn,  and  the  two  forms  are  easily 
distinguishable;  but  in  some  cases  the  growths  so  in- 
volve the  margin  of  the  anus  on  both  its  mucous  and 
cutaneous  surfaces  that  it  is  impossible  to  say  to  which 
class  they  properly  belong.  They  are  partly  covered 
by  skin  and  partly  by  mucous  membrane;  they  may  in 
great  measure  be  replaced  within  the  bowel,  but  not 
entirely;  and  they  turn  out  again  on  the  least  straining 
or  exertion;  and  they  are  liable  to  bleed,  which  none 
of  the  other  forms,  described  as  purelv  external,  ever 
do. 

Again,  there  is  the  large  internal  hemorrhoid, 
shown  in  Fig.  2.  This  arises  from  the  rectum  proper, 
and  may  go  on  developing  for  years  before  it  ever  ap- 
pears outside  of  the  sphincter.  While  still  c(M'npara- 
tively  small,  and  before  the  patient  has  ever  had  any 
protrusion  at  stool,  it  may  give  rise  to  all  of  the  symp- 
toms of  hemorrhoids,  except  those  due  to  the  forcing 
of  the  tumors  outside  the  body.  In  other  words,  the 
patient  may  have  pain,  bleeding,  discomfort  in  defeca- 
tion, pain  in  the  loins,  thighs  and  legs,  slight  mucous 
discharge  with  or  between  the  passages,  itching  to  an 
annoying  extent,  and  often  a  train  of  reflex  nervous 
.symptoms,  and  yet  never  have  any  protrusion;  and  the 
physician  must  use  care  in  his  diagnosis  and  learn  to 
detect  these  tumors  by  digital  examination  alone;   for 


—    27    — 

the  condition  is  one  for  which  patients  in  the  higher 
walks  of  life  not  "infrequently  seek  relief,  and  much 
good  may  be  done  by  treatment. 

Finally,  there  is  the  nevoid  condition,  often  spoken 
of  as  the  capillary  hemorrhoid.  In  this  form  the 
tumor  is  never  large;  never,  I  think,  large  enough  to 
protrude  from  the  anus  even  with  straining.  The  dis- 
ease is  rather  a  group  of  enlarged  capillary  blood- 
vessels than  a  connective  tissue  growth.  This  is 
usually  situated  just  within  the  verge  of  the  anus,  and 
when  seen  looks  like  the  surface  of  a  strawberry.  The 
mucous  membrane  covering  it  is  generally  eroded, 
and  the  slightest  touch  with  a  probe  is  often  sufficient 
to  set  up  a  free  arterial  hemorrhage.  This  is  the 
bleeding  hemorrhoid  par  fxcellencf,  but  it  often  causes 
hardly  any  other  symptoms. 

Suppose,  now,  that  an  enema  has  been  given  and 
there  is  no  protrusion,  and  yet  the  patient  complains 
of  bloody  passages  and  some  pain.  By  gently  draw- 
ing apart  the  margins  of  the  anus  a  bright  red,  straw- 
berry-looking surface  appears  just  within  the  margin 
when  the  patient  strains  down.  There  is  little  tumor; 
nothing  comes  outside  when  the  patient  has  a  passage, 
and  yet  he  or  she  is  nearly  bloodless  from  the  daily 
hemorrhage  in  the  closet.  The  finger  is  passed  up 
the  bowel,  and  no  changes  are  found.  A  slight 
touch  on  the  strawberry-like  surface  occasions  a 
free  flow  of  blood,  sometimes  arterial  and  in  jets,  at 
others  bright  red.  but  not  per  saJfeni.       The  diagnosis 


—     2$    — 

is  made,  and  the  patient  is  suffering  from  what  is 
known  as  a  capillary  hemorrhoid. 

Some  time  since  I  was  asked  by  Dr.  Watson,  of 
Jersey  City,  to  see  with  him  a  case  with  the  following 
history. 

The  lady  had  been  suffering  for  a  considerable 
time  from  occasional  severe  hemorrhages  from  the 
bowel.  These  occurred  at  considerable  intervals,  and 
never  while  at  stool,  but  always  some  time  after  the 
natural  evacuation.  Half  an  hour  or  so  after  relieving 
the  bowels  she  would  feel  the  desire  for  a  second 
movement,  and  this  would  be  composed  in  great 
measure  of  bright  arterial  blood,  sometimes  reaching 
half  a  pint  in  quantity.  The  history  being  given,  a 
digital  e.xamination  was  made,  and  nothing  found. 
By  careful  examination  of  the  anus  a  strawberry 
growth  was  seen,  which  bled  freely  on  the  merest 
touch.  I  could  see,  when  we  reached  the  next  room 
and  I  gave  my  diagnosis,  that  it  was  looked  upon  by 
the  other  medical  gentlemen  present  with  considerable 
doubt,  and  I  therefore  strengthened  it  with  the  offer 
that  if,  after  one  or  two  applications  of  strong  nitric 
acid  to  this  spot,  the  bleeding  did  not  cease,  I  would 
come  again  to  the  city  where  this  patient  lived  and 
make  another  examination  under  ether,  without  fee. 
The  application  was  made  and  the  patient  was  cured. 

'J'here  is  apparently  no  limit  to  the  amount  of 
blood  a  patient  may  lose  from  this  form  of  disease. 
Onlv  recentlv  I  saw  in  consultation  a  case  of  bleeding 


—    29    — 

ti)  the  point  of  absolute  exsaiiguination  from  these 
tumors.  The  patient  was  a  poor  man  in  the  tenement- 
house  district,  who  had  bled  at  each  passage  till  his 
pulse  was  120,  his  complexion  waxy,  and  till  he  fainted 
three  or  four  times  a  day.  He  attempted  a  passage 
at  my  request  while  making  the  examination,  and 
when  lifted  from  the  commode  he  had  evacuated  fully 
half  a  pint,  if  not  more,  of  bright  red  blood.  He  had 
no  disease  except  these  bright  red  arterial  hemor- 
rhoids, and  they  caused  no  protusion  at  stool.  It 
hardly  seemed  possible  that  such  a  grave  general  state 
could  result  from  so  slight  a  local  disease,  but  the  cure 
of  the  local  condition  cured  the  patient. 


CHAPTER  III. 

TREATMENT. 

Before  undertaking  the  treatment  of  a  case  of 
hemorrhoids  both  patient  and  surgeon  should 
come  to  a  distinct  understanding.  The  latter  can 
assure  the  sufferer  that  he  may  be  cured  at  once  and 
forever  if  he  desires,  and  this  applies  to  all  forms  of 
the  disease.  The  only  cases  in  which  this  cannot  be 
said  are  those  in  which  the  patient  is  in  such  bad  gen- 
eral condition  that  no  interference  is  justifiable.  If 
he  be  suffering  from  advanced  disease  of  heart  or  kid- 
neys, for  example,  and  at  the  same  time  be  troubled 
with  old  hemorrhoids,  it  may  be  safer  to  do  what  can 
be  done  by  palliative  measures  and  avoid  anything 
like  radical  treatment.  This  is  the  only  thing  that 
should  prevent  the  surgeon  from  attempting  a  positive 
cure.  Ordinary  disease  of  the  lungs  has  never  pre- 
vented me  from  operating  and  getting  a  good    result. 

Just  at  this  point  the  surgeon  will  have  many 
questions  to  answer,  and  one  of  the  most  common  is 
whether  nature  did  not  intend  that  a  great  many 
people  should  have  a  painful  affection  of  the  rectum 
which  should  make  a  part  of  their  lives  miserable  and 
cause  them  to  lose  two  or  three  ounces  of  blood  every 
time  they  go  to  the  closet ;  and  whether  it  is  safe  for 
the  sufferer  to  have  this  beautiful  condition  interfered 
with  ?     This  question  will  come  from  very    intelligent 


people,  who  will  back  it  up  with  the  authority  of  some 
physician,  that  by  suffering  in  Uiis  way  they  are  es- 
caping something  worse.  Should  the  same  physician 
who  advises  that  this  daily  bleeding  be  allowed  to 
continue,  make  a  practice  of  opening  a  vein  in  his 
patient's  arm  once  a  day  for  years,  and  withdrawing 
the  same  amount  of  blood,  what  would  be  thought  of 
his  practice  ?  And  yet  one  would  be  as  good  practice 
as  the  other. 

The  iiext  question  will  be  whether  the  patient  can 
be  cured  without  an  operation,  and  at  exactly  this 
point  many  a  patient  will  disappear.  The  answer  will 
depend,  as  will  be  shown  presently,  upon  the  form  of 
trouble  present.  Many  cases  can  be  cured  without 
an  operation,  and  many  more  by  procedures  so  trivial 
that  they  carry  no  terror  in  the  thought,  but  some  can 
not.  In  the  latter  class  of  cases  the  young  practitioner 
must  not,  for  his  own  sake,  allow  himself  to  be  placed 
at  a  disadvantage  which  is  pretty  sure  to  end  dis- 
astrously. 

Unfortunately  for  the  public  they  almost  all  con- 
sider themselves  pretty  well  educated  on  the  subject 
of  piles.  Cures  "without  knife,  ligature,  or  caustic" 
have  caught  their  eyes  in  the  daily  press  for  years, 
and  they  come  to  their  doctor  not  to  be  guided  by  his 
judgment,  but  to  have  him  relieve  them  if  he  can  do 
so,  subject  to  the  restrictions  they  may  impose.  The 
conditions  are  these.  "  If  you  can  cure  me  without 
an    operation  I  am  willing   to    be    cured,  otherwise    I 


_     32     — 

prefer  to  be  let  alone."  There  is  no  blame  to  the 
patient  in  this,  for  he  has  a  perfect  right  to  make  his 
own  bed  and  lie  in  it  ;  and  it  may  be  possible  for  the 
physician  to  do  as  he  desires  and  cure  him  without 
ether,  without  confining  him  to  his  bed,  and  without 
any  "operation,"  as  he  considers  an  operation.  But 
the  young  surgeon  must  not  be  too  anxious  for  the 
case.  He  may  be  forced  to  say  "  what  you  desire  is 
impossible,"  and  let  his  patient  go;  but  he  never  must 
be  led  into  a  line  of  practice  which  is  not  safe,  for 
when  trouble  comes  no  mercy  will  be  shown  him. 
The  patient  is  practically  doctoring  himself,  with  a 
physician  to  assist  him,  and  in  his  heart  he  knows  it. 
The  case  goes  badly  and  the  doctor  has  all  the  blame 
and  deserves  it.  The  rule  in  my  own  practice  is,  1 
believe,  the  only  one  to  be  followed;  after  my  examina- 
tion I  recommend  the  method  of  cure  which  seems  to 
me  the  best,  and  from  that  1  never  allow  myself  to  be 
shaken.  If  it  seems  to  the  physician  that  the  clamp 
should  be  used  he  must  in  honesty  use  it,  and  not 
allow  himself  to  be  placed  by  his  patient  in  the  false 
and  untenable  position  of  recommending  one  treat- 
ment as  best  and  then  employing  another.  To  be 
.sure  he  will  occasionally  see  his  patient  go  elsewhere, 
but  less  often  than  he  fears;  and  on  the  other  hand 
he  will  avoid  bad  surgery  with  its  unpleasant  con- 
sequences. He  must  make  up  his  mind  at  first  that  a 
great  many  patients  had  rather  suffer  all  their  lives 
than  be  cured  by  any  operation  even  as  safe  and  pain- 


—  33  — 

less  as  this;  and  he  may  strive  to  find  some  method 
of  curing,  or  at  least  relieving  this  class  which  is  free 
from  the  terror  of  a  cutting  operation  ;  but  he  will 
probably  discover  in  his  search  that  hemorrhoids  are 
bad  things  to  experiment  upon,  and  his  first  accident 
will  greatly  dampen  his  ardor,  in  the  light  of  the  fact 
that  he  already  has  at  his  hand  a  means  of  cure  which 
surgically  leaves  little  to  be  desired.  On  this  point 
let  me  say  that  the  profession  in  general,  the  great 
body  of  practitioners  scattered  over  the  country,  are 
being  unduly  worried  about  a  particular  scheme  of' 
curing  hemorrhoids  by  injections.  The  secret  remedy 
is  known,  it  has  been  faithfully  tried  in  hospital  and 
private  practice  by  representative  men  both  in  Europe 
and  America  ;  it  will  be  fully  described  in  the  course 
of  this  little  book,  and  its  advantages  and  disadvan- 
tages copmpared  with  other  recognized  means  of  treat- 
ment. I  also  venture  to  predict  that  as  a  popular 
quack  remedy  it  has  seen  its  best  days  ;  for  the  re- 
action in  the  public  mind  has  already  begun,  and 
where  a  year  or  so  ago  every  patient  was  determined 
to  have  nothing  but  carbolic  acid,  they  now  not  in- 
frequently are  just  as  anxious  to  have  nothing  to  do 
with  it. 

If  the  surgeon  wishes  to  try  this  method  of  treat- 
ment, at  the  demand  of  the  patient,  he  is  justified  in 
doing  so;  but  it  is  not  equally  adapted  to  all  cases,  and 
in  some  respects  its  action  is  very  uncertain,  as  will  be 
shown  later. 

4  A 


—  34  — 

Some  patients  will  deliberately  choose  a  course 
of  palliative  treatment,  even  knowing  that  it  is  not 
curative,  rather  than  to  be  cured  by  surgical  means. 
For  such,  the  practitioner  must  be  prepared  to  furnish 
what  relief  he  can,  and  this  is  often  very  great,  though 
we  cannot  now  enter  into  the  details  of  treatment. 

Though  it  is  difficult  to  conceive  of  a  case  of 
hemorrhoids  that  cannot  and  ought  not  to  be  cured, 
where  the  patient  is  in  any  condition  to  bear  treatment, 
there  are  some  which  can  only  be  cured  after  prolonged 
preparatory  treatment,  and  these  are  generally  in 
women.  The  doctor  who  does  much  rectal  practice 
becomes  of  necessity  very  familiar  with  many  of  the 
diseases  of  women.  He  will  not  be  long  in  practice 
before  he  encounters  the  following  combination.  A 
lady  comes  to  him  with  hemorrhoids,  upon  which  he 
operates  with,  perhaps,  the  usual  good  result,  though 
possibly  only  obtained  after  rather  a  slow  and  painful 
recovery.  In  the  course  of  a  few  months  the  disease 
has  returned,  or  it  may  be  that  she  has  never  been  en- 
tirely well  since  the  operation.  Another  examination 
is  made,  and  the  patient  is  found  to  have,  in  addition 
to  the  hemorrhoids,  an  enlarged  uterus  with  a  lacerated 
cervix,  a  ruptured  or  greatly  relaxed  perineum,  and  a 
proctocele,  all  of  which  should  have  been  cured  before 
the  operation  for  hemorrhoids  was  attempted. 

Many  patients  dread  the  taking  of  ether  more 
than  the  operation  itself,  and  will  refuse  radical  treat- 
ment on  this  account.     When   cocaine  was  first   intro- 


—  35  — 
duced  I  had  great  hope  that  this  objection  might  i^v 
the  future  be  overcome,  but  the  drug  has  not  fully 
reaHzed  the  expectations  held  concerning  it.  Never- 
theless it  answers  in  a  great  many  cases,  and  should 
always  be  at  hand.  By  it  small  tumors  tnay  be  removed 
with  absolute  painlessness,  and  I  have  operated  bot[? 
with  ligature  and  clamp  under  its  influence,  with  great 
satisfaction  in  some  cases  of  large  tumors,  but  have 
been  disappointed  in  others,  before  I  found  out  by 
frequent  trials  the  limits  of  its  applicability. 

Where  the  tumor  or  tumors  to  be  removed  are 
small,  or  where  a  single  large  one  can  be  separated 
from  others  and  cocaine  be  injected  with  the  hypoder- 
mic syringe  into  the  exact  part  where  the  ligature  o: 
clamp  is  to  be  applied,  the  drug  will  give  satisfactory 
results.  In  this  way  several  large  tumors  may  be 
operated  upon  at  one  sitting,  or  at  intervals  of  tei\ 
days  or  more,  and  the  patient  cured.  But  where  the 
whole  margin  of  the  anus  is  involved  and  turns  out 
with  the  hemorrhoids,  and  where  it  is  necessary  to 
bring  the  entire  circumference  of  the  rectum  for  y 
considerable  distance  upwards  under  its  influence,  the 
drug  is  apt  to  be  unsatisfactory;  for  the  reason  that  tv 
bring  all  parts  of  the  wall  under,  its  influence  at  one 
time,  as  is  necessary  in  stretching  the  sphincter,  dan- 
gerous symptoms  may  be  produced  before  a  sufficient 
quantity  of  cocaine  has  been  injected  to  permit  of 
painless  operation. 

In  the  New  \'ork  Medical  Journal,  Auiiust  7.  iS.SO, 


-  3^  - 
1  reported  a  case  of  this  sort.  It  was  necessary  to 
♦)ilate  the  sphincters,  and  with  a  large  speciUum  care- 
fully examine  an  exceedingly  sensitive  ulcer  for  a  blind 
fistulous  track  emptying  into  it.  One  hundred  and 
twenty  minims  of  4  per  cent,  solution  of  cocaine  were 
mjected  into  eight  different  points  around  the  circum- 
ference of  the  anus  without  giving  sufficient  anaesthesia 
li)  operate  with  any  comfort;  and  on  account  of  symp- 
toms of  general  cocaine  poisoning  which  developed,  the 
operation  was  finished  with  ether. 

The  recent  suicide  of  Dr.  Kolomnin  was  caused 
by  a  somewhat  simjlar  case  of  ulceration  of  the  rectum, 
which  he  endeavored  to  scrape  under  cocaine.  After 
three  injections  of  six  grains  each  the  rectum  was  still 
^^ensitive;  after  another  six  grains,  he  was  enabled  to 
operate  with  tolerable  anaesthesia,  but  the  patient  died 
of  the  drug,  and  Kolomnin  took  his  own  life. 

The  only  explanation  I  have  of  the  difficulty  in 
•^•etting  anaesthesia  of  the  whole  of  the  lower  end  of 
the  bowel  without  sometimes  using  doses  of  the  drug 
which  are  dangerous,  is  the  actual  very  large  extent  of 
surface  to  be  affected,  and  the  great  number  of  sensi- 
tive nerves  to  be  brought  into  local  contact  with  the 
*solution.  On  the  whole,  my  experience  has  been,  that 
in  minor  operations  the  drug,  when  used  hypodermi- 
cally,  is  perfectly  satisfactory;  but  in  larger  ones  it  is 
r.ot  to  be  relied  upon  absolutely,  and  may  have  to  be 
supplemented  with  ether. 

I.et   us  now  consider  in    detail   the   treatment   of 


~  37  — 

each  of  the  varieties  of  tumor  described  in  the  last 
chapter,  and  I  shall  hope  to  do  so  in  a  manner  whicU 
will  enable  the  practitioner  to  answer  his  patients'  o?> 
repeated  question,  '*  how  do  you  treat  piles  ?"  with  the 
simple  statement,  ''  In  a  great  many  ways,  depending 
on  the  case." 

The  treatment  of  the  first  variety,  that  in  which  j 
vein  has  ruptured  and  there  is  a  small,  exquisitely; 
painful  tumor  at  the  margin  of  the  anus,  is  very  simple 
The  suffering  is  due  entirely  to  the  tension  and  press- 
ure caused  by  the  clot,  and  this  should  be  turned  ou: 
of  its  bed  by  transfixing  the  tumor  and  laying  it  opei; 
The  knife  for  this  purpose  should  be  a  very  sharp - 
pointed,  curved  bistoury  with  small  and  delicate  blade. 
The  point  is  entered  on  the  anal  aspect,  carried  di- 
rectly through  the  tumor  in  the  direction  of  the  radiat- 
ing folds,  and  then  made  to  cut  its  way  out,  the  whole 
procedure  hardly  occupying  an  instant  of  time.  Co- 
caine need  not  be  used,  for  to  inject  it  into  the  tumc. 
is  as  painful  as  the  incision,  and  to  rub  it  on  the  sur- 
face is  almost  useless.  The  clot  may  easily  be  ex- 
pressed, if  it  does  not  follow  the  knife,  and  the  incis- 
ion should  be  filled  with  styptic  cotton.  There  will 
generally  be  some  oozing  of  blood,  and  this  shouhi 
always  be  stopped  completely  before  the  patient  leave:-i 
the  office.  A  good  way  is  to  cover  the  wound  with 
ordinary  lint,  place  over  this  a  large,  hard  pad  made 
of  a  couple  of  towels,  and  let  the  patient  sit  for  a  fev/ 
minutes  on  a  hard  chair  with  the  pad  in  place  for  pres- 


-  3S  - 

stirc.  When,  after  a  second  examinatit)n,  the  l)leed- 
'.ng  has  been  found  to  have  ceased,  directions  must  be 
.civen  to  repeat  the  pressure  in  the  same  way  at  the 
patient's  own  home,  should  it  return. 

This  is  an  operation  which  I  occasionally  take  the 
liberty  of  performing  without  consulting  the  patient's 
wishes;  but  if  it  be  explained  to  him  and  he  refuses 
the  instant  relief  which  it  is  sure  to  give,  then  he 
should  be  directed  to  buy  an  ice-bag,  fill  it  with  finely 
broken  ice,  go  home  and  go  to  bed,  have  his  bowels 
freely  moved  with  a  saline  purge,  put  on  the  ice  and 
i}ear  his  pain  till  nature  relieves  him,  which  may  be  in 
one  of  two  ways,  and  may  take  from  three  days  to  ten. 
'I'he  tumor  may  gradually  subside  as  the  clot  shrinks 
i  p  and  thus  relieves  the  pain,  or  it  may  go  on  to  sup- 
puration and  end  either  in  spontaneous  cure  or  in  a 
vmall  subcutaneous  fistula. 

The  second  form  of  external  hemorrhoid,  the 
vwollen  and  painful  tag  of  skin  which  often  has  a  fis- 
sure at  its  base,  contains  no  clot  to  be  released,  and 
therefore  instead  of  being  incised  should  be  cut  off, 
wfter  a  few  drops  of  cocaine  have  been  injected  into  its 
substance.  'I'his  may  also  be  done  in  the  office,  and 
I  he  same  method  used  to  stop  the  oozing  of  blood  as 
iii  the  other  case.  When  the  tumor  has  become  pain- 
It^ss  to  the  t(nich  with  cocaine,  it  is  seized  with  a 
small  j)air  of  hooked  forceps,  gently  drawn  upon,  and 
•.  ut  off  at  its  ba.se  with  a  single  closure  of  a  pair  of 
•■;out  and  sharp  scissors.     There  will  be  a  little  pain  in 


—  39  — 

the  cut  for  a  day  or  two,  and  that  is  all.  The  wound 
generally  heals  very  kindly,  but  should  any  application 
be  necessary  a  ten-grain  solution  of  nitrate  of  silver  on 
a  brush,  or  a  dressing  with  a  few  shreds  of  very  fine 
lint  will  cause  rapid  cicatrization. 

There  may  be  more  than  one  of  these  tags  to  be 
removed,  and  they  may  be  cut  off  at  one  time  or  at 
different  visits,  as  the  patient  prefers. 

In  the  third  variety  (Fig.  5)  the  cutaneous  tumors 
are  larger  and  more  difficult  to  manage.  Inasmuch  as 
they  are  seldom  seen  to  any  such  extent  as  is  figured 
except  in  connection  with  more  serious  disease  within 
the  bowel,  their  treatment  is  secondary  to  the  disease 
above.  I  seldom  should  operate  on  the  tags  for 
example  unless  at  the  same  time  I  were  operating  for 
the  stricture  or  the  ulceration.  If  the  patient  be  under 
ether  and  the  stricture  is  divided,  the  external  growths 
may  be  snipped  off  with  the  scissors;  but  otherwise 
there  will  be  plenty  to  occupy  the  mind  of  the  surgeon 
within  the  bowel  without  stopping  for  this  secondary 
trouble,  the  importance  of  which  is  very  slio^ht  in  con- 
nection with  that  of  the  primary  disease. 

The  fourth  form — the  varicose  dilatation  of  the 
veins  of  the  anus  without  hypertrophy  of  the  skin — 
had  better  in  most  cases  be  left  undisturbed,  unless 
there  be  some  special  indication  for  interference.  Ex- 
cept where  the  patient  is  very  nervous  and  over-sensi- 
tive, such  a  condition  will  cause  no  real  trouble;  and 
in  all  the  cases    I    have   ever   seen    the    suft'erinof  was 


—  40  — 

more  mental  than  physical.  However,  1  have  been 
forced  to  relieve  patients  of  this  source  of  annoyance 
more  than  once,  and  I  have  done  it  in  various 
ways.  When  he  strains  down  it  is  at  once  apparent 
that  we  have  to  deal  with  a  small  tumor  composed  of 
one  or  more  enlarged  veins,  often  appearing  through 
the  delicate  skin  to  be  the  size  of  a  lead  pencil,  and 
perfectly  distinguishable  by  their  dark  color.  The 
question  is,  what  to  do.  Ablation  alone  I  have  never 
tried,  fearing  hemorrhage.  Once  only  have  I  injected 
such  a  vein  with  a  15-per-cent.  solution  of  carbolic 
acid,  seen  it  in  a  few  seconds  solidify  and  turn  whitish, 
and  subsequently  slough — an  experiment  w^hich  for 
obvious  reasons  I  do  not  care  to  repeat.  I  have  used 
electrolysis  with  better  results,  but  although  the  tumor 
has  coagulated  and  decreased  in  size,  there  has  been 
considerable  pain  and  soreness  for  some  days.  Now, 
when  compelled  to  operate,  I  prefer  the  clamp,  know- 
ing that  though  the  operation  may  seem  formidable 
for  so  slight  an  affection,  it  is  at  least  safe  and  not  at 
all  liable  to  be  attended  by  untoward  accident. 

There  remains  but  one  other  of  these  minor  affec- 
tions— the  capillary  bleeding  tumor  within  the  sphinc- 
ter. For  this  I  use  fuming  nitric  acid  on  the  end  of  a 
stick;  and  it  is  the  only  form  of  tumor  in  which  I  be- 
lieve nitric  acid  to  be  indicated.  Here  the  slough 
which  follows  a  thorough  application  of  this  kind  will 
completely  cure  the  disease,  and  by  a  single  applica- 
tion a  hemorrhage  may  be  stopped  that  has  kept  tlie 
patient  exsanguinated  for  years. 


CHAPTER  IV. 

THE    LIGATURE. 

Of  all  the  time-honored  operative  procedures 
known  to  the  profession  for  the  cure  of  hemorrhoids  it 
is  but  a  waste  of  time  to  discuss  at  the  present  day 
more  than  two — the  ligature  and  the  clamp.  The  first 
of  these  owes  its  present  prominence  to  Allingham,  and 
is  often  described  as  his  operation.  In  the  way  now 
generally  performed  the  name  is  correct,  though  the 
treatment  by  ligature  is  very  old. 

The  principle  of  his  method  is  to  dissect  the 
hemorrhoidal  tumor  away  from  its  attachments  for  a 
certain  extent,  and  then  to  surround  the  remainder  of 
the  base  with  a  tight  silk  ligature.  His  belief  is 
that  the  chief  arterial  supply  to  the  tumor  comes  from 
above,  and  that  all  of  the  lower  part  may  be  dissected 
away  from  the  muscular  coat  without  causing  any 
serious  bleeding;  while  the  ligature  thrown  around 
what  remains  is  an  effectual  barrier  against  hemor- 
rhage. The  advantage  of  this  method  is  that  the 
ligature  is  not  placed  around  the  skin  at  the  margin  of 
the  anus,  for  this  is  divided  with  the  scissors  before  it 
is  applied,  and  the  ligature  lies  in  the  groove  thus 
made,  and  by  this  means  much  pain  is  avoided,  and 
much  time  is  saved  in  the  treatment. 

Regarding  the  details  of  the  operation  but  little 
need  be  said,  so  simple  is  it  in  its  performance.       The 


—   4-^    — 

tumor  to  be  tied  is  seized  with  strong  forceps  and 
drawn  down,  the  patient  having  been  etherized  and 
the  sphincter  previously  dilated. 

With  strong  scissors  the  lower  attachments  of  the 
tumor  all  around,  and  especially  the  point  of  junction 
of  the  mucous  membrane  with  the  skin,  are  divided; 
the  ligature  encircles  what  remains,  is  tied  as  tightly  as 
possible;  both  ends  are  cut  off  short,  and  the  greater 
part  of  the  tumor  below  the  ligature  is  also  cut  off, 
only  sufficient  being  left  to  form  a  good  and  safe 
stump  for  the  ligature  to  hold.  The  patient  is  pre- 
pared for  the  operation  by  the  previous  administration 
of  a  purgative,  and  the  bowels  are  confined  for  a  week 
or  so  after  its  performance,  and  then  relieved  by  a 
cathartic. 

This,  in  brief,  is  the  operation  practiced  by  AUing- 
ham,  and  it  is  an  exceedingly  good  one.  I  began  my 
own  practice  by  always  performing  it,  and  did  I  not  be- 
lieve that  something  else  was  better,  should  perform  it 
still.  It  is  as  safe  as  any  operation  can  well  be,  and 
when  properly  done,  it  cannot  fail  to  cure;  and  per- 
fect safety  and  surety  are  two  great  points  to  be  gained 
in  any  operation. 

But  a  considerable  experience  with  this  opera- 
tion led  me  after  a  time  to  begin  the  search  for  some- 
thing just  as  safe  and  ju.st  as  sure  without  some  of  the 
objections  which  any  large  number  of  cases  will  be 
sure  to  show  pertain  to  this  method. 

The  first  objection  which  developed   itself  in   my 


—  43  — 
own  practice  was  the  great  pain  which  the  patient 
often  suffered  for  the  first  week  or  ten  days.  AlHng- 
ham  distinctly  claims  that  after  the  patient  has  re- 
covered from  the  ether  there  is  often  no  pain.  I  can 
only  say  that  though  this  is  sometimes  the  case,  it  is 
by  no  means  the  rule  in  my  own  practice,  or  that  of 
other  American  surgeons.  My  explanation  of  the  pain 
I  have  often  seen  is  that  a  nerve  is  compressed  by  the 
ligature  as  well  as  an  artery;  but  no  matter  what  the 
explanation,  the  fact  remains  that,  having  followed 
Allingham's  method  in  every  particular,  1  have  more 
than  once  been  forced  to  keep  the  patient  constantly 
under  the  influence  of  morphine  till  the  ligature  came 
away;  and  I  know  that  many  others  have  had  a  simi- 
lar experience. 

A  second  objection  was  the  frequent  necessity  for 
the  passage  of  the  catheter  for  several  days  after  the 
operation. 

A  third  was  the  amount  of  blood  lost  during  the 
operation,  and  the  frequent  necessity  for  leaving  a 
considerable  wad  of  lint  in  the  rectum  on  account  of 
the  oozing,  which  caused  great  subsequent  suft'ering 
and  was  only  removable  after  three  or  four  days,  and 
then  with  considerable  pain. 

A  fourth  was  the  length  of  time  required  by  my 
patients  before  they  were  able  to  resume  active  busi- 
ness. 

It  will  be  seen  that  none  of  these  objections  were 
of*  vital  importance.     The  patients  still  recovered  and 


—  44  — 

were  radically  cured,  and  in  the  end  were  satisfied  in 
spite  of  these  difficulties;  but  still  there  seemed  to  me 
an  opportunity  for  a  more  satisfactory  operation. 

For  these  reasons  I  wais  finally,  by  the  advice  of 
Henr}'  Smith,  led  to  adopt  another  operative  procedure, 
which  on  the  whole  has  served  me  better.  I  still  oc- 
casionally use  the  ligature,  but  I  never  apply  it  where 
any  of  the  sensitive  tissue  at  the  margin  of  the  anus  is 
included  in  the  loop.  If  a  tumor  be  well  circumscribed 
and  pedunculated,  and  a  ligature  can  be  thrown 
around  its  base  and  still  be  well  above  the  external 
sphincter,  it  may  be  applied  without  causing  any  great 
amount  of  reflex  irritation,  and  hence  of  pain.  In  this 
way  I  have  not  infrequently  seized  a  prolapsing  tumor 
of  considerable  size,  injected  it  with  cocaine,  and  after 
a  few  minutes  tied  a  string  around  its  base  and  cut  it 
off  without  having  much  subsequent  pain.  But  when 
it  comes  to  a  case  of  large,  prolapsing,  internal  hem- 
orrhoids, involving  the  margin  of  the  anus  and  attended 
by  a  good  deal  of  the  eversion  of  the  skin,  which  is 
shown  in  Fig.  2,  1  prefer  another  operation,  because  I 
believe,  though  no  safer  and  no  more  certain  to  cure, 
it  will  cause  less  subsequent  pain,  and  less  confinement 
to  the  house  and  bed,  than  the  ligature. 


CHAPTER  V. 

TREATMENT   BY   INJECTIONS. 

As  far  as  my  own  influence  has  gone  1  have  done 
what  I  could  to  take  this  method  of  treatment  from 
the  hands  of  the  quacks  and  place  it  upon  a  recognized 
basis.  In  the  July  number  of  the  "American  Journal 
of  the  Medical  Sciences,"  1885,  I  reported  about  two 
hundred  cases  treated  by  this  plan  with  very  satisfac- 
tory results,  and  in  "The  New  York  Medical  Journal," 
Nov.  14,  1885,  in  answer  t(^  numerous  questions,  1 
ofave  full  and  definite  directions  as  to  its  methods  of 
application. 

The  fact  that  since  then  1  have  had  a  succession 
of  bad  and  troublesome  cases  treated  by  this  means, 
and  that  these  cases  have  led  me  in  a  measure  to  be 
less  hopeful  of  the  results  of  the  method,  in  no  way 
invalidates  the  reports  of  my  own  carefully-observed 
cases  up  to  that  time.  In  writing  now  I  shall  use  less 
glowing  terms  than  I  did  then,  but  I  have  by  no  means 
abandoned  the  practice.  It  is  still,  to  my  mind,  a  very 
good  way  of  treating  a  great  many  cases:  having  in 
certain  points^ exceptional  advantages  over  all  others; 
and  in  the  fact  that  it  does  not  apply  equally  well  to  all, 
and  that  it  will  occasionally  be  followed  by  disagree- 
able consequences,  it  in  no  way  differs  from  other 
operations.  I  say  this  so  plainly  in  the  beginning  be- 
cause  I   have  so  frequently  been  accused  of  having 


—  46   - 

first  advocated  the  practice  and  subsequently  aban- 
doned it;  while  all  that  I  have  really  done  has  been  to 
state  fully  and  freely  the  objections  to  it,  as  at  other 
times  I  have  with  equal  plainness  stated  the  advantages 
f)f  it.  It  is  now  at  a  point  where  every  practitioner 
may  try  it  for  himself,  and  come  to  his  own  conclusions 
regarding  its  value.  All  that  can  be  said  of  my  own  prac- 
tice is,  that  while  for  a  year  or  more  1  used  it  almost 
exclusively  and  was  much  pleased  with  its  results,  a 
succession  of  bad  cases  have  led  me  to  modify  my 
views  of  its  value  and  universal  applicability,  and  that, 
though  I  now  use  it  constantly,  it  is  only  in  selected 
cases. 

For  years  back  a  great  number  of  irregular  and 
often  very  ignorant  practitioners  have  been  travelling 
around  the  country  injecting  and  ciiriui;  hemorrhoids 
with  solutions  of  carbolic  acid.  The  in.strument  was 
an  ordinary  hypodermic  syringe,  the  solution  was  for 
a  long  time  a  secret,  but  was  finally  discovered  to  be 
pure  carbolic  acid  mixed  with  oil,  or  glycerin  and 
water,  in  certain  proportions.  About  the  success  of 
their  treatment  there  could  be  no  question  in  a  great 
many  well  authenticated  cases  upon  ordinarily  intelli- 
gent patients,  who  said  that  they  simply  felt  the  pricks 
of  a  needle  and  were  cured.  By  this  simple  process 
large  hemorrhoids  which  had  been  bleeding  and  pro- 
truding for  years  disappeared  after  a  single  visit,  and 
this  often  without  any  subsequent  pain  or  symptoms 
of  any  sort.     So  often  was  this   delightful    story   told 


—  47   — 

)iie  by  patients  upon  whom  1  had  recommended  other 
and  to  them  more  formidable  procedures,  that  I  was 
at  last  driven  in  pure  self-defense  to  try  and  discover 
what  there  was  in  this  practice,  and  I  therefore  armed 
myself  with  several  preparations  of  carbolic  acid — 
a  15  per-cent. — 3.3  per-cent. — 50  per-cent.  and  the 
pure  acid — and  proceeeded  to  inject  them  into  a  large 
proportion  of  my  cases. 

The  results  in  many  cases  were  surprisingly  good. 
Some  were  cured  without  being  confined  to  the  house 
at  all,  and  without  any  pain  which  interfered  with 
their  daily  occupations.  Others  did  not  do  quite  as 
well.  They  complained  of  severe  pain  coming  on  an 
hour  or  so  after  the  injection  and  lasting  several  hours, 
but  it  was  rare  to  have  them  give  up  their  work  and 
go  to  bed,  or  to  use  the  opium  suppositories  with 
which  they  were  provided  in  case  of  necessity.  Once 
in  a  while  the  injection  would  cause  a  slough  and  this 
would  put  an  end  to  the  treatment  for  a  couple  of 
weeks  till  it  had  healed,  but  the  pain  of  this  condition 
was  generally  bearable  and  the  patients  expressed 
themselves  as  perfectly  satisfied  and  greatly  preferring 
even  this  amount  of  suffering  to  any  "operation". 
The  cures  also  seemed  to  be  permanent,  none  of  my 
patients  returned  with  a  fresh  protrusion  of  the  tumors 
which  had  once  been  operated  upon,  even  after  an  in- 
terval of  four  years.  At  this  time  it  was  rare  for  mt 
to  have  the  tumors  slough  after  an  injection.  Gener- 
ally there  was  a  hardening  and  shrinking  of  the  hem- 


—  4«  — 

orrhoid  sufficient  to  prevent  either  hemorrhage  or 
protrusion,  and  this  was  produced  by  solutions  of  ;^;^ 
per-cent.  and  15  per-cent. 

At  this  time  I  published    my  cases    and    also    the 


Fig.  7. 

rules  which  were  to  be    followed    in    this    method    oi 
treatment. 

The  solutions  of  carbolic  acid  were  made  in  pure 
water  with  sufficient  glycerine  added  to  make  a  per- 
fectly clear  and  colorless  mixture,  and  of  these  I  kept 
constantly  ready  one  of  15  per-cent.  one  of  33  per- 
cent., and  another  of  50  per-cent. 


—  49  — 

The  glycerin  and  carbolic  acid  should  both  be 
perfectly  pure,  and  as  soon  as  the  solution  began  tc» 
turn  yellowish  it  was  discarded. 

The  needles  should  be  fine   and    sharp,  and    the  . 
syringe  in  perfect  working  order — one  with  side  hand- 
les is  preferable — and  after  each   time  the   syringe   is 
used  it  should    be  thoroughly  washed    out    and    left 
standing  in  fresh  water. 

Before  making  an  application  give  an  enema  of 
hot  water,  and  let  the  patient  strain  the  tumors   as 
much  into  view  as  possible.     Then   select   the  larger 
and  deposit  five  drops  of  the  solution  as  near   the- 
centre  of  the  tumor  as  possible,  taking  care  not  to  go- 
too  deep  so  as  to  perforate  the  wall  of  the  rectum  and' 
inject  the  surrounding  cellular    tissue.     The    needle- 
should  be  entered  at  the  most  prominent  point  of  the  • 
tumor.     If  the  hemorrhoid  does  not  protrude  from 
the  anus,  a  tenaculum  may  be  used   to  draw  it  inter 
view.     After  the  injection  has  been   made   the   parts- 
should  be  replaced,  and  the  patient  kept  under  obser- 
vation for  a  few  minutes  to  see  that  there  is  no  unusual 
pain.     The  injection  will  cause  some  immediate  smart- 
ing if  it  is  made  near  the  verge  of  the  anus;  if  made 
above  the  external  sphincter,  the  patient  may  not  feel 
the    puncture   or   the    injection  for  several   minutes., 
when  a  sense  of  pressure  and  smarting  will  be  appre- 
ciated.    In  some  cases  no  pain  will  be  felt  for  half  an 
hour,  but  then  there  will  be   considerable   soreness, 
subsiding  after  a  few  hours.     If  it  increases,  instead  of 


s  A 


disappearing,  and  on  the  following  day  there  is  con- 
^i-derable  suffering,  which  may  not  perhaps  be  suffi- 
*  ient  to  keep  the  patient  on  his  back,  but  is  still 
enough  to  make  him  decidedly  uncomfortable;  it  is  a 
pretty  good  indication  that  a  slough  is  about  to  form. 
For  the  reason  that  it  is  impossible  to  tell  absolutely 
what  the  effect  of  an  injection  is  to  be  until  at  least 
twenty-four  hours  have  passed,  it  is  better  to  make  but 
one  at  a  visit  and  to  wait  till  the  full  effect  of  each 
one  is  seen  before  making  another.  If  on  the  second 
day  there  is  no  pain  or  soreness,  another  tumor  may 
be  attacked;  and  this  will  often  be  the  case. 

By  following  these  rules  all  went  well  for  a  time, 
but  soon  I  began  to  be  troubled  with  a  constant 
succession  of  sloughs  with  their  attendant  pain,  and 
the  worst  of  the  trouble  was  that  I  never  knew 
beforehand  when  a  slough  was  likely  to  be  caused. 
My  old  solutions  were  all  discarded  and  new  ones 
made  to  replace  them;  the  syringes  were  all  sent 
away  and  renewed;  and  yet  the  sloughs  continued 
and  I  began  to  expect  to  encounter  this  objec- 
tion whenever  an  injection  was  made,  for  the 
strength  of  the  solution  or  the  character  of  the  hemor- 
rhoid seemed  to  make  no  difference.  A  solution  of 
15  per  cent,  would  cause  sloughing  where  one  of  50 
per  cent,  or  even  of  the  pure  acid  would  produce  only 
a  circumscribed  induration,  and  2>ice  7)ersa;  so  that 
after  a  time  I  was  forced  to  confess  that  I  had  no 
means  of  determining  beforehand  whether  the  patient 


_  51  — 

was  to  undergo  the  pain  of  an  inflamed  and  sloughing; 
hemorrhoid,  though  the  injection  made  should  be  of 
lo  per  cent  or  of  pure  acid. 

The  next  complication  was  the  occasional  occur- 
rence of  small  marginal  abscesses  after  injections,  and 
as  these  always  caused  a  great  deal  of  pain  this  was  a 
serious  objection.  They  usually  appeared  three  or 
four  days  after  the  injection,  were  situated  just  at  the 
verge  of  the  anus,  causing  a  tumor  about  the  size  of 
the  end  of  the  thumb,  covered  partly  by  skin  and  partly 
by  mucous  membrane.  They  showed  a  decided  ten- 
dency to  break  on  both  the  mucous  and  cutaneous 
surfaces  and  leave  a  short,  subcutaneous  track  con- 
necting the  two  openings. 

These  marginal  abscesses  were  never  at  the  point 
of  the  injection,  though  always  on  the  same  side  of  the 
gut;  sometimes,  in  fact,  they  were  fully  two  inches 
below  the  injection. 

Still,  these  complications  were  not  of  sufficient 
gravity  to  cause  an  abandonment  of  this  plan  of  treat- 
ment. The  small  abscesses  caused  a  good  deal  of 
pain  but  were  not  serious  in  their  ultimate  conse- 
quences; and  the  sloughs  healed  kindly  with  the  aid  of 
local  applications,  though  they  greatly  prolonged  the 
time  of  treatment,  as  I  always  thought  it  best  to  dis- 
continue the  injections  after  once  a  slough  had  formed 
until  it  was  entirely  healed. 

There  are,  however,  still  other  objections  to  this 
method  of  treatment.    In  my  own  practice  I  have  had 


—  52  — 

one  case  of  diffuse  inflammation  and  suppuration, 
lymphangitis,  ischio-rectal  abscess,  and  deep  fistula, 
following  a  single  injection  of  strong  acid  into  a  small 
tumor;  and  I  have  heard  of  other  cases  in  the  practice 
of  other  surgeons.  I  believe  that  this  serious  acci- 
dent was  due  to  landing  the  strong  acid  entirely  be- 
low the  tumor  and  under  the  muscular  coat,  but  I 
cannot  be  sure. 

Again,  within  the  past  year  1  have  twice  been 
called  upon  to  treat  a  rare  form  of  fistula  arising 
directly  from  injections.  These  fistulae  were  of  the 
blind,  internal  variety,  having  an  opening  near  the 
anus  within  the  sphincters,  and  a  track  running  up- 
wards from  this,  under  the  mucous  membrane,  for  a 
considerable  distance,  and  ending  in  a  cul-de-sac. 
One  of  these  cases  was  in  my  own  practice,  and  three 
different  tracks  of  this  kind  existed,  each  of  which  I  have 
no  doubt  was  caused  by  an  injection  of  carbolic  acid, 
made  by  myself.  As  I  have  no  objection  to  reporting 
my  own  bad  cases,  that  others  may  derive  the  same 
benefit  from  them  that  I  do,  I  will  give  this  in  full. 

The  patient  was  a  professional  man  of  middle 
age,  who  had  long  been  a  sufferer  from  hemorrhoids 
of  large  size,  and  was  in  a  very  weak  condition,  hav- 
ing lost  much  blood,  become  dyspeptic  and  nervous, 
and  having  slight  pulmonary  trouble.  The  tumors 
were  quite  large,  the  sphincter  much  relaxed,  and  the 
margin  of  the  anus  very  much  like  what  is  shown  in 
Fig.  2.     Injections  were  made  several  times,  the  so- 


—  53  — 

lutions  used  being  the  weaker  ones  and  never  exceed- 
ing 33  per  cent.  On  the  day  following  the  first  one 
the  following  entry  was  made  in  the  case-book: 
"  Considerable  pain  following  first  injection.  Patient 
has  been  in  bed  most  of  the  time."  Two  days  later 
the  following  entry  was  made:  "The  single  injection 
of  five  drops  of  a  solution  of  carbolic  acid  (one  to 
twelve)  has  caused  great  pain  up  to  the  present  time. 
The  patient  has  been  able  to  be  about  more  or  less, 
but  has  suffered  constantly  and  taken  considerable 
quantities  of  opium.  Examination  shows  the  mass  of 
tumors  on  one  side  black,  inflamed,  and  angry-look- 
ing; and  though  the  injection  was  placed  in  a  small 
nodule,  springing  from  the  centre  and  most  prominent 
portion  of  this  mass,  the  whole  group  has  become  in- 
volved in  the  inflammation  it  has  caused."  Three 
months  later  the  following  note  appears:  "The  pa- 
tient has  had  considerable  sloughing  of  the  tumors, 
following  the  injections  of  a  ^$  per  cent,  solution,  and 
has  had  one  marginal  abscess,  leaving  a  subcutaneous 
fistula  which  has  been  cut.  He  is  now  in  great  meas- 
ure relieved."  In  exactly  four  months  from  the  be- 
ginning of  the  treatment  the  patient  was  discharged 
cured — that  is,  he  considered  himself  cured,  there 
being  no  more  protrusion,  except  as  the  margin  of  the 
anus  tended  to  roll  outwards,  and  no  bleeding.  Nine 
months  after  the  first  injection  he  visited  me  and  still 
reported  himself  as  having  no  symptoms.  Eighteen 
months  from  the  time  treatment  began  the   patient 


—  54  — 

again  reported  with  several  hemorrhoids,  which  were 
attached  high  up  the  bowel,  and  had  only  recently 
begun  to  appear  at  the  anus,  and  a  few  days  later  the 
following  note  was  made:  ''Two  injections  (33  per 
cent.)  without  trouble.  Yesterday,  third  injection  of 
^^  per  cent,  into  a  distinct  tumor.  To-day,  slough, 
size  of  a  silver  quarter,  irregular  in  shape,  and  in  ad- 
dition, a  marginal  swelling,  size  of  a  walnut."  The 
slough  separated,  cicatrization  progressed  slowly,  and 
at  the  end  of  a  month  the  patient  went  away,  having 
no  more  hemorrhoids,  but  in  their  place  an  unhealed 
ulcer,  which  seemed  to  be  doing  well  and  bid  fair  to 
be  entirely  healed  in  a  few  days. 

One  year  later  he  reappeared  and  reported  that 
this  ulcer  had  never  entirely  healed,  but  had  gone  on 
discharging  and  causing  pain  ever  since.  After  sev- 
eral examinations,  I  discovered  three  of  the  blind 
internal  fistulae  already  described,  and  in  addition,  two 
more  large  internal  hemorrhoids.  The  patient  having 
now  been  under  treatment  two  years  and  a  half,  he 
was  etherized  and  operated  upon.  The  fistulae  were 
laid  open,  and  the  hemorrhoids  removed  with  the 
clamp,  and  the  patient  finally  discharged  cured. 

I  have  noticed  that  each  of  these  fistulae  were  of 
the  submucous  variety,  running  in  the  connective 
tissue  between  the  mucous  and  muscular  layers,  as  it 
might  be  inferred  that  they  would  be;  for  the  acid 
is  deposited  by  the  needle  between  these  two  layers, 


-  56  - 

and  the  amount  of  sloughing  it  causes  is  not  Hmited 
to  the  point  at  which  it  is  introduced. 

It  may  perhaps  be  instructive  to  record  one  {>r 
two  more  cases. 

In  June,  1885,  I  was  called  upon  to  treat  an  old 
gentleman,  the  mayor  of  a  small  town  in  Ohio,  living 
in  a  high,  cool,  country  region,  but  much  depressed 
with  business  losses  and  worry.  He  came  to  Nev/ 
York  in  the  middle  of  the  hot  season  and  submitted 
to  treatment.  The  hemorrhoids  were  the  worst  which, 
up  to  that  time,  I  had  ever  treated  by  this  method. 
The  sphincter  was  much  relaxed;  the  tumors  had  bte^\ 
down  for  twenty-five  years  without  being  replaced, 
and  were  very  large  and  vascular.  There  were  three 
distinct  masses,  each  about  the  size  of  a  hen's  egg. 
The  case  was  not  an  attractive  one,  considering  th<? 
age  and  condition  of  the  patient  and  the  hot  weather, 
but  I  undertook  it.  Into  the  largest  of  the  three 
tumors  I  injected  five  drops  of  a  fifty-per-cent.  solu- 
tion. It  was  followed  by  a  good  deal  of  pain  and  loss 
of  sleep  for  two  nights,  with  some  con.stitutional  dis- 
turbance. On  the  third  day,  the  pain  of  the  first  in- 
jection having  somewhat  subsided,  I  injected  five 
drops  of  pure  acid  into  the  second  tumor,  and  had 
much  less  trouble  than  with  the  fifty-per-cent.  solution 
in  the  former  case.  After  three  days  more  I  agaiit 
injected  the  same  amount  of  pure  acid  into  the  third 
tumor.  Both  of  these  last  applications  caused  a  dis- 
tinct slough  with  resulting  ulcerated  surface  and   free 


-  56  - 

discharge  of  bloody  matter.  After  a  few  days  more  I 
returned  to  the  first  tumor,  which  had  not  sloughed, 
t>ut  simply  become  indurated,  and  injected  five  drops 
-»:>f  pure  acid  into  that.  The  applications  were  all 
Blade  within  the  space  of  two  weeks.  During  this 
period  the  patient  allowed  his  bowels  to  become  con- 
-stipated,  and  I  had  to  clean  them  out  with  repeated 
i:opious  enemata.  There  was  at  one  time  some  vesical 
irritation  and  decrease  in  the  amount  of  urine,  whether 
from  direct  absorption  of  carbolic  acid  or  from 
reflex  irritation  I  do  not  know,  and  at  the  end  of  the 
treatment  the  patient  was  considerably  reduced  in 
-strength — so  much  so  that  I  put  him  upon  the  most 
nourishing  regimen  with  bark  and  whisky.  Just  as  he 
■seemed  on  the  point  of  rallying  I  discovered  a  small 
abscess  in  the  perinaeum,  which  was  opened,  and 
Siealed  kindly,  having  no  connection  with  the  rectum. 
After  recovering  from  this  and  gaining  a  considerable 
flegree  of  health  he  went  home  to  Ohio,  and  was  im- 
mediately brought  to  bed  with  a  second,  larger  abscess 
-on  the  buttock.  From  this  he  also  made  a  good  re- 
lovery,  and  for  one  year  he  had  no  rectal  symptoms 
whatever,  but  at  the  end  of  that  time,  he  informed  me, 
i)leeding  had  returned,  and  though  I  have  not  seen 
him,  I  have  little  doubt  that  he  is  suffering  again  from 
4he  same  tumors.* 

This    patient    had    his    own    way.      He    was    not 

*  Previously   reported   in    part.    N     Y.    Medical   Journal, 
3Jov.  14.  1S35. 


—  57  — 

''operated  upon" — but  he  would  have  had  less  suffer- 
ing and  less  confinement  if  he  had  been.  Moreover, 
he  would  have  been  radically  cured. 

Let  us  now  take  another.  *A  man  of  about  sixty 
has  had  hsemorrhoids  for  twenty  years.  He  is  of 
sedentary  habits  and  nervous,  but  with  no  other  dis- 
ease than  the  tumors.  An  examination  shows  a  very 
advanced  case  of  long-standing  trouble.  The  tumors 
can  be  divided  into  four  chief  ones — one  posterior, 
one  anterior,  and  one  on  each  side;  but  two  of  these 
are  as  large  as  hen's  eggs,  and  the  others  only  a  trifle 
smaller  They  spring  from  above  the  sphincter,  and 
are  entirely  covered  by  mucous  membrane ;  the 
sphincter  is  so  relaxed  that  they  protrude  with  the 
slightest  exertion,  and  the  patient  has  worn  a  rectal 
supporter  for  years. 

It  is  a  beautiful  case  for  the  clamp,  and  fit  for 
that  only  ;  but  at  the  outset  I  am  met  fairly  by  the 
not  infrequent  obstacle — ''no  operation."  Argument 
is  useless  ;  he  has  heard  of  carbolic  acid  ;  in  fact,  his 
physician  has  sent  him  to  me  for  that  treatment,  and 
it  is  that  or  nothing.     Unwillingly  I  consent. 

An  injection  of  thirty-three  per-cent.  is  made 
posteriorly,  and  with  the  usual  caution  and  instruction 
the  patient  goes  home.  Two  days  later  he  returns. 
He  has  had  pain — yes  considerable  ;  but  he  does  not 
mind  the  pain  as  long  as  he  can  avoid  an  operation. 


♦Previously  reported,  N.  Y.  Med.  Record,  Aug.  7,  1S86. 


-  58  - 

Another  injection  of  the  same  strength  on  the  left 
side. 

It  is  four  days  before  he  again  appears,  and  they 
have  been  passed  mostly  in  bed,  and  he  has  used 
several  suppositories,  but  he  is  now  better,  and  "  if  it 
is  no  worse  than  this  he  can  stand  it."  The  tumor 
injected  last  time  is  much  smaller,  but  the  posterior 
one,  which  was  first  attacked,  is  not  much  benefited, 
and  five  drops  of  pure  acid  are  placed  in  its  centre. 

Three  days  later  he  reports  that  he  is  beginning 
to  be  better,  that  there  is  less  protrusion  at  stool,  and 
he  has  left  off  his  supporter.  The  last  injection  ha« 
not  caused  a  slough,  but  a  hard  inflammatory  indura- 
tion in  the  centre  of  the  tumor.  Another  five  drops 
of  pure  acid  are  injected  into  the  same  mass  at  a  little 
distance  from  the  hard  spot,  and  he  then  tells  me  that 
ever  since  his  last  visit  he  has  had  considerable  diffi- 
culty in  passing  water,  which  is  high-colored  and 
diminished  in  amount. 

Four  days  later,  says  he  had  no  very  severe  pain 
after  the  last  application,  and  straining  at  stool  fails 
to  bring  down  either  of  the  tumors  which  have  been 
operated  upon.  Another  injection  of  pure  acid  into 
the  anterior  tumor,  the  largest  of  them  all.  Three 
days  later  he  reminds  me  that  he  is  in  a  great  hurry 
to  go  away  on  business,  and  is  anxious  to  have  treat- 
ment crowded  more  rapidly.  He  had  no  pain  at  all 
after  last  injection,  and  fears  I  did  not  get  it  in.  The 
injection  has  again  caused  a  hard  lump    of    inflamma- 


—  59  — 
tory  induration,  but  no  slough,  and  a  decrease  of 
about  one-third  in  the  size  of  the  mass.  There  is  still 
more  work  to  be  done  on  the  first  one,  and  another 
five  drops  of  pure  acid  are  injected  into  it,  causing  no 
pain  at  the  time,  or  after,  as  he  tells  me  two  days 
later. 

Thus  far  all  had  gone  well,  and  three  of  the 
tumors  had  been  treated  without  accident.  An  in- 
jection of  pure  acid  v/as  made  into  the  last  one,  that 
on  the  right  side.  Three  days  later  I  am  sent  for  to 
come  to  him.  Before  this  he  has  come  to  me,  but  he 
has.  been  in  bed  ever  since  the  last  injection;  the 
urine  has  been  very  scanty  and  passed  with  difficulty  ; 
there  is  an  enlarged  and  painful  gland  in  the  right 
groin  ;  and  a  painful  swelling  at  the  verge  of  the  anus 
on  the  right  side,  circumscribed,  the  size  of  an 
almond.  Eleven  days  later,  the  patient  being  still 
confined  in  bed,  the  abscess  at  the  margin  of  the  anus 
was  opened  and  a  drachm  or  so  of  pus  evacuated.  A 
couple  of  days  later  it  was  found  to  have  also  opened 
spontaneously  on  the  mucous  side  of  the  swelling,  just 
within  the  sphincter.  Ten  days  later  this  was  healed. 
The  patient  had  then  been  under  treatment  just  forty 
days.  He  was  much  better  ;  the  tumors  were  all  con- 
siderably reduced  in  size,  they  still  protruded  at  stool, 
but  went  back  spontaneously,  and  he  promised  to 
report  again  in  a  few  days.     He  never  did. 

In  this  case,  also,  the  patient  would  have  been 
much  better  off,  both  during  the  treatment  and  in  the 


—  6o  — 

end,  had  he  been  operated  upon  in  my  way  instead  of 
his  own.  In  fact,  it  is  a  few  such  cases  as  this  that 
have  led  me  to  lay  down  the  invariable  rule  of  practice 
to  which  I  have  referred — to  select  the  mode  of  treat- 
ment which  seems  to  me  most  appropriate,  and  never 
allow  myself  to  be  led  into  another  which  I  do  not 
think  as  good,  simply  because  the  patient  wishes  it. 
These  cases  are  the  bad  ones,  and  I  would  not 
convey  the  idea  that  all  are  like  them.  They  illustrate 
exceedingly  well  all  of  the  objections  to  this  plan  of 
treatment  which  I  have  ever  encountered,  except  the 
single  one  of  deep  inflammation  and  suppuration. 
They  may  be  enumerated  in  the  following  order: 

1.  Pain. 

2.  Ulceration. 

3.  Marginal  abscess. 

4.  Fistula. 

5.  The  impossibility  of  giving  any  definite  prog- 
nosis as  to  the  length  of  time  necessary  to  effect  a 
cure,  or  the  amount  of  suffering  the  treatment  will 
entail. 

6.  The  fact  that  the  treatment  may  not  result  in 
a  radical  cure,  but  that  the  tumors  may  reappear. 

There  is  still  one  other  complication  which  may 
arise,  and  this  is  decided  vesical  symptoms,  whether 
from  carbolic  acid  poisoning  or  merely  from  reflex 
irritation,  I  have  never  been  able  to  decide.  I  have 
seen  the  urine  decidedly  diminished,  and  great  pain 
in  passing  it,  after  injections  of  the  stronger  prepara- 


—  6i   — 

tions,  but  I  have  never  seen  the  typical  train  of  symp- 
toms following  carbolic  acid  poisoning. 

It  will  be  seen  that  none  of  these  objections  are 
vital.  Any  of  the  well-recognized  methods  of  opera- 
tion are  attended  by  some  pain,  and  occasionally  by 
untoward  accidents.  I  do  not  consider  the  operation 
by  injection  as  dangerous  to  life,  and  1  have  never  yet 
heard  of  a  fatal  case;  and  in  all  of  my  experience  with 
the  method  I  have  never  had  but  one  serious  compli- 
cation— a  single  case  of  deep  suppuration,  and  even 
this  I  think  can  be  avoided  by  the  use  of  weaker  so- 
lutions placed  more  superficially. 

There  is  still  one  point  about  which  there  should 
be  no  misunderstanding.  From  all  the  information 
attainable,  I  believe  that  my  experience  with  this 
method  is  about  that  of  the  irregular  practitioners 
who  thrive  by  it,  and  that  the  proportion  of  cures, 
without  any  pain  or  bad  symptoms,  obtained  by  them 
is  practically  the  same  as  my  own.  I  have  certainly 
tried  all  of  the  solutions  ordinarily  used  by  them,  and 
some  besides.  The  tincture  of  iron  and  the  fluid  ex- 
tract of  ergot  are  two  from  which  I  hoped  for  better 
results,  but  neither  seemed  to  possess  any  advantages. 
From  cases  which  have  from  time  to  time  come  to  my 
knowledge,  I  know  that  abscesses,  ulceration  and 
great  pain  are  by  no  means  unusual  sequelae  in  the 
practice  of  these  gentlemen.  It  is  not  long  singe  one 
of  this  fraternity  was  forced  by  his  patient  to  return 
the  fee  which  had  been  paid  in  advance,  after  the  pa- 


—    62     — 

tient  had  been  confined  to  his  house  for  several  weeks 
with  a  deep  abscess;  and  only  a  few  days  ago  I 
operated  with  the  clamp  upon  a  gentleman  who  had 
previously  had  a  single  injection  made  by  one  of  these 
men,  had  been  confined  to  his  bed  with  it  for  a  month, 
and  had  then  abandoned  the  treatment.  He  had  been 
particularly  unfortunate,  as  he  had  subsequently  had 
a  ligature  applied  by  another  practitioner,  which,  as 
he  described  it,  "slipped  on  the  fourth  day,"  and  he 
had  then  abandoned  that  treatment  also. 

I  believe  I  have  now  fairly  stated  the  advantages 
and  disadvantages  of  this  plan  of  operating  upon 
hemorrhoids,  and  have  put,  as  far  as  my  own  experi- 
ence enables  me,  each  reader  in  position  to  choose  for 
himself  whether  he  will  use  it  or  not. 

The  question  in  fact  narrows  itself  down  to  this. 
On  the  one  hand  we  have  a  method  of  treatment  which 
is  safe,  certain  and  practically  painless;  but  which  in- 
volves the  administration  of  ether,  the  performance  of 
what  the  patient  dreads,  a  surgical  operation,  and  a 
certain  confinement  to  the  house  for  a  few  days.  On 
the  other  hand  we  have  a  method  which  avoids  the 
ether,  the  surgical  operation,  and  perhaps  the  con- 
finement to  the  house;  but  which,  in  fact,  involves 
fully  as  much  of  an  operation  as  the  other,  only  more 
quickly  performed,  and  without  ether,  and  which  is 
neither  radical  nor  certain  in  its  results.  It  is  in  fact 
this  uncertainty  as  to  the  course  of  a  case  after  an  in- 
jection, and  the  fact  that  the  operation  may  not  result 


-  63  - 

in  a  radical  cure  even  though  it  may  be  followed  by 
serious  complications,  which  keeps  me  from  employ- 
ing this  method  oftener  than  the  complications  them- 
selves, or  the  possible  dangers.  I  have  never  aban- 
doned the  idea  that  the  patient  should  submit  to  the 
judgment  of  his  physician  as  to  his  treatment,  and  I 
am  not  convinced  that  the  surgeon  should  yield  his 
preference  for  a  method  of  treatment  which  long  ex- 
perience has  proved  to  be  as  safe  and  certain  as  any 
operation  in  surgery,  to  the  foolish  prejudices  of  a 
timid  patient. 

As  regards  the  comparative  suffering  caused  by 
the  two  operations,  the  clamp  and  the  injections,  it 
may  be  taken  for  a  fact  that  any  considerable  number 
of  cases  will  show  greater  pain  spread  over  a  longer 
time  with  the  latter  than  with  the  former:  and  all  the 
patient  actually  gains  in  the  most  favorable  case  is  the 
avoidance  of  a  safe  operation  which  he  fears,  while  he 
submits  to  an  uncertain  one  which  he  does  not  fear  be- 
cause of  his  ignorance;  together  with  a  few  days  of 
liberty  during  which  he  would  be  better  off  in  his 
room. 

Should  the  surgeon  decide  to  employ  this  method 
the  following  points  may  not  be  useless: 

Use  the  weaker  solutions  in  preference  to  the 
stronger. 

Never  use  it  in  any  of  the  forms  of  external 
tumors  already  described. 


-  64  — 

In  cases  of  large,  prolapsing,  and  long-standing 
disease  expect  pain  and  perhaps  marginal  abscesses. 

Be  very  cautious  in  prognosis  as  to  the  time  the 
treatment  will  require,  and  the  amount  of  pain  it  will 
cause.  In  fact  it  will  generally  be  safer  to  acknowl- 
edge the  uncertainty  as  to  these  two  important  points 
of  the  operation. 

The  form  of  disease  best  adapted  for  this  treat- 
ment is  the  tumor  of  moderate  size,  having  a  well- 
defined  pedicle,  and  springing  from  the  wall  of  the 
bowel  entirely  above  the  sphincter.  Such  may  be  re- 
placed within  the  bowel  after  the  injection,  and  are 
very  likely  never  again  to  be  heard  from;  and  in  them, 
should  sloughing  occur  it  will  be  attended  by  the 
minimum  amount  of  suffering. 

The  injection  of  hemorrhoids  with  carbolic  acid, 
though  apparently  a  simple  and  trivial  affair,  is  to  be 
regarded  in  the  light  of  a  surgical  operation,  and 
should  not  be  undertaken  by  the  practitioner  until  he 
has  surrounded  himself  and  the  patients  with  all  the 
safeguards  at  his  command. 


CHAPTER  VI. 

THE  CLAMP  AND  CAUTERY. 

After  what  has  been  said,  the  reader  may  be 
tempted  to  ask  whether  we  possess  any  means  of 
curing  hemorrhoids  which  is  safe,  certain,  and  free 
from  comphcations,  and  in  this  chapter  I  shall  answer 
that  question  in  the  affirmative. 

The  operation  with  the  clamp  is  generally  known 
as  that  of  Mr,  Henry  Smith  of  London,  and  to  him  it 
owes  its  general  introduction  and  acceptance  by  the 
profession,  as  does  the  ligature  to  Mr.  Allingham, 
though  he  claims  no  originality  in  the  method  itself 
but  only  in  some  of  its  details. 

The  essential  idea  of  this  operation  is  to  seize  the 


Fig.  8.— Pile  Forceps: 

part  to  be  removed,  apply  the  clamp  to  its  base,  cut  it 
off  with  scissors,  and  cauterize  the  stump.  The  clamp 
acts  merely  as  a  temporary  ligature  to  prevent  bleed- 
ing during  the  operation  ;  and  the  cautery  is  to  pre- 
vent bleeding  after  the  clamp  has*  been  removed. 
The  instruments  which  are  indispensable  are  therefore 

6    A 


—  66  — 

four  in  number — a  hook  forceps  to  seize  the  pile, 
shown  in  Fig.  8;  the  clamp  shown  in  Fig.  9;  scissors; 
and  the  cautery. 


Fig.  9. — Author's  Clamp. 

The  clamp  is  a  modification  of  Mr,  Smith's  which 
I  have  had  made  for  my  own  convenience,  and  the 
difference  can  be  seen  at  a  glance.  Mr.  Smith's  in- 
strument. Fig.  10,  is  armed  with  ivory  shields  to   pre- 


FiG.  10.— Smith's  Clamp. 
vent  the  possible  effects  of  radiated  heat;  it  has 
scissor  handles;  and  the  edges  of  the  blades  are 
smooth.  In  my  own  there  are  no  shields,  the  handles 
are  much  larger,  and  the  blades  are  serrated.  I  was 
led  to  abandon  the  ivory  shields  because  I  found 
them  practically  unnecessary  and  because  they   made 


-67- 

the  instrument  more  cumbersome.  The  handles  were- 
modified  to  give  increased  power  and  to  avoid  the 
general  use  of  the  screw  for  closing  the  blades.  The^ 
edges  were  serrated  to  add  to  the  crushing  force,  but 
experience  has  convinced  me  that  even  with  thi.-. 
amount  of  power  the  clamp  is  incapable  of  crushing; 
the  tissues  to  any  extent.  I  have  placed  it  on  a  tumor, 
screwed  it  up  to  its  greatest  possible  power,  and  left 
it  in  this  condition  for  fifteen  minutes.  While  it  was- 
in  position  the  hemorrhoid  became  cold  and  livid,  but 
when  the  pressure  was  removed  the  vessels  immedia- 
tely filled  up  and  the  circulation  was  restored.  It  is 
for  this  reason  that  I  say  the  clamp  acts  merely  as  a 
provisional  ligature  during  the  operation.  In  fact  no 
force  capable  of  crushing  the  tissues  to  the  point  of 
causing  the  occlusion  of  the  vessels  and  the  death  of 
the  parts  can  be  exercised  without  much  greater 
mechanical  power  than  this  clamp  possesses.  There 
can  be  no  bleeding  while  the  clamp  is  in  position,  if 
the  handles  are  firmly  closed  with  one  hand  ;  but  un- 
less the  cut  surface  has  been  thoroughly  cauterized, 
there  will  be  immediate  bleeding  on  its  removal.  The 
advantage  of  the  form  of  handle  shown  in  my  instru- 
ment over  that  of  Mr.  Smith's  is  that  an  adequate 
pressure  can  be  kept  up  for  any  length  of  time  with- 
out the  intervention  of  the  screw,  and  by  this  fact  the 
length  of  time  consumed  in  operating  is  much  dimin- 
ished. 

The  cautery  is  the  most  important  of  all  the  in-^ 


—  68  — 

-struments,  being  the  most  delicate.  The  latest  modi- 
fications of  Paquelin's  instrument  leave  little  to  be 
-desired.     If  the  operator  prefer,  he  may  use  the  gal- 

vano-cautery,  and  with  a  storage-battery  this  is  a  very 
convenient  form  of  instrument,  but  I  have  not  yet  in 
any  own  practice  abandoned  my  old  favorite  for  the 
-newer   invention.     The   Paquelin   cautery  is  shown  in 

Fig.  II,  and  maybe  obtained  from  Tiemann  &  Co..  of 
;Kew  York,  at  a  cost  of  about  thirty  dollars. 


Fig.   II. — Paquelin  Cautery. 

Its  beauty  lies  in   its  reliability  and  portability, 
^nd  for  these  rea.sons   I  always  carry  it  with  me  for 


-69  - 

operating  at  long  distances  from  home.     Filled  before- 
starting,  it  can  always  be  used  on  the  following  day». 
and  generally  after  two  days;  and  should  the  opera 
tion  be  very  extensive,  as  in  cases  of  cancer,  it  is  only- 
necessary  to  be  provided  with  an  additional   ounce  or 
two  of  benzine.     The   instrument  merely  requires  to 
be  properly  understood  and  managed  to  secure  per- 
fect reliability,  though   I   always  carry  an   extra  pla 
tinum  blade,  to  be  secure  against  the  temporary  dis- 
abling of  one  which  generally  is  due   to  the   lack  of 
experience  of  an  assistant. 

The  scissors  need  only  to  be  strong  and   moder 
ately  long,  though  a  slight  curve   in  the  blades  wiU 
sometimes  be  found  an  advantage. 

Very  little  preparation  for  this  operation  will  be 
found   necessary  in  a   healthy  patient.     When   one  in 
good  health  tells  me  his  bowels  are  acting  regularly,  Y 
have   about  abandoned   the  time-honored   custom  of 
deranging  their  action  with  a  purgative  just  previous 
to  this  operation,   and   if   they   have   moved    on   the 
morning  of  the   operation,  all  that  is  necessary  is  a 
simple  enema  of  soap-suds  an  hour  before  the  opera 
tion  begins.     If  given  an  hour  before,  it  will  generally 
all  be  passed   before  the   arrival   of  the  surgeon.     Ir 
given  after  the  arrival   of  the   operator,   he  stands  a- 
good  chance  of  receiving  a  large  portion  of  it  in  his- 
lap   and   on   his   towels   the    moment    he    dilates   the- 
sphincter. 


The  operation  is  performed  in  the  following  man- 
ner: 

As  a  rule  the  patient  is  etherized,  though  unless 
there  is  a  good  deal  of  tissue  to  be  removed  at  the 
verge  of  the  anus,  the  operation  may  be  done  with 
cocaine.  Ether  should  be  advised  in  almost  every 
case,  and  cocaine  only  used  as  a  substitute;  for  al- 
though a  tumor  which  is  visible  may  be  removed  with 
the  latter,  it  is  difficult  to  thoroughly  stretch  the 
sphincter  under  its  influence,  and  by  omitting  this  two 
great  advantages  of  ether  are  lost — the  chance  to 
thoroughly  search  the  rectum,  and  the  avoidance  of 
the  pain  following  the  operation  which  is  secured  in 
part  by  a  complete  paralysis  of  the  sphincters.  Many 
hemorrhoids  which  are  not  visible  at  an  ordinary  ex- 
amination will  become  visible  after  a  patient  has  been 
etherized  and  his  sphincter  dilated,  and  it  is  an  awk- 
ward thing  to  assure  a  patient  that  he  is  radically 
cured  because  three  or  four  perfectly  visible  tumors 
have  been  removed,  and  have  him  return  in  a  few 
weeks  with  one  or  two  more,  which  were  overlooked 
at  the  operation  simply  because  they  did  not  crowd 
themselves  into  view. 

The  tumors  are  next  seized  and  removed  one  by 
one.  No  speculum  is  necessary  for  this,  but  if  one  be 
used,  a  medium-sized  blade  of  Sim's  vaginal  speculum, 
or  the  retractor  shown  in  Fig.  3,  will  be  found  most 
convenient.  The  tumor  is  seized  with  the  forceps  and 
held  by  the  left  hand  till  the  clamp  is  applied  with  the 


—  71  — 

right.  The  forceps  are  next  detached,  the  tumor  cut 
off  with  the  scissors  (but  not  so  short  but  that  a  good 
firm  stump  remains)  and  the  cautery  is  then  taken 
from  the  assistant,  whose  sole  duty  should  be  to  have 
it  always  ready,  and  applied  thoroughly  to  the  stump 
of  the  hemorrhoid.  No  haste  should  be  used  in  this 
step  of  the  operation.  The  pedicle  should  be  thorough- 
ly charred  with  the  platinum  at  a  dull  red  heat.  When 
this  has  been  done,  the  clamp  may  be  loosened  with- 
out being  removed,  to  see  if  any  vessel  in  its  grasp  is 
still  inclined  to  bleed,  and  if  a  bleeding  point  appear 
it  is  again  tightened,  and  the  cautery  is  again  applied. 
Thirty  seconds  is  an  abundance  of  time  for  each 
tumor,  and  I  have  often  done  four  to  the  minute— the 
greater  part  of  this  being  devoted  to  the  thorough  ap- 
plication of  the  cautery. 

When  all  have  been  removed,  the  stumps  will 
naturally  retract  within  the  sphincter,  and  no  dressing 
will  be  necessary. 

The  thing  most  difficult  for  the  unpracticed 
operator  to  understand  is  at  just  what  point  to  apply 
the  clamp,  and  this  can  best  be  learned  by  experience, 
as  it  really  constitutes  the  delicate  point  in  the  opera- 
tion. There  is  no  difficulty  when  the  tumor  is  an  in- 
ternal one  arising  fairly  from  the  mucous  membrane 
above  the  sphincter,  and  not  involving  the  skin  of  the 
anus.  In  such  a  case  the  clamp  does  not  implicate  the 
the  muco-cutaneous  junction  at  the  anus,  and  remov- 
ing too  little  tissue  will  not  leave  unsightly  and  annoy- 


—  72  — 

ing  tags  of  skin,  nor  will  removing  more  than  is  neces- 
sary result  in  cicatricial  contraction  to  a  serious  ex- 
tent. But  where  the  margin  of  the  anus  tends  to  roll 
over,  as  is  shown  in  Fig.  2,  considerable  experience  is 
necessary  to  learn  just  how  much  tissue  to  include  in 
the  clamp. 

In  such  a  case  a  groove  should  be  made  with  the 
scissors  in  the  cutaneous  border  for  the  application  of 
the  clamp  so  that  no  skin  may  be  included  in  its  grasp. 
If  this  groove  is  made  at  the  line  of  junction  of  muc- 
ous membrane  and  skin  marked  in  the  figure,  painful 
tags  of  skin  will  certainly  be  left,  which  will  cause 
subsequent  annoyance,  and  considerably  detract  from 
the  success  of  the  operation.  If,  on  the  other 
hand,  all  the  protruding  mass  be  cut  off,  and  the 
clamp  be  applied  in  the  groove  where  the  protrusion 
joins  the  anus,  too  great  contraction  is  apt  to  result 
except  in  cases  where,  on  account  of  a  very  lax 
sphincter,  it  is  deemed  advisable  actually  to  reduce 
the  size  of  the  orifice.  The  endeavor  must  be  to  so 
draw  the  lines  between  these  two  extremes  in  an  ordi- 
nary case  as  to  leave  no  tags  after  cicatrization,  for 
these  are  always  unsightly,  generally  annoying,  and 
sometimes  subject  to  a  subacute  inflammation  which 
renders  it  desirable  to  remove  them  by  a  subsequent 
operation  with  cocaine. 

When  it  is  necessary  to  divide  the  skin  of  the 
anus  with  the  scissors  before  applying  the  clamp,  there 
will  be  a  little  bleeding,  but  when  the  clamp  is  used 


—  73  — 

without  any  preparatory  cutting  the  operation  is  al- 
most bloodless,  and  under  any  circumstances  it  is  un- 
necessary to  soil  more  than  a  single  towel.  This  is  a 
great  desideratum  in  cases  of  enfeebled  patients,  be- 
sides enabling  the  operator  to  have  his  wounds  per- 
fectly dry  without  the  use  of  any  lint  or  other  dressing. 

The  operation  with  the  ligature,  as  done  by 
Allingham,  by  previously  cutting  away  a  part  of  the 
attachment  of  the  tumor,  is  by  no  means  bloodless, 
and  unless  the  operator  takes  the  risk  of  being  called 
back  after  a  few  hours  to  stop  the  oozing  of  blood,  he 
is  apt  to  use  considerable  lint,  and  having  pressed  it 
into  the  wounds  to  leave  it.  This  is  a  constant  source 
of  pain,  and  often  it  is  practically  impossible  to  re- 
move it  before  the  end  of  the  third  or  fourth  day, 
when  it  has  become  thoroughly  loosened  by  the  dis- 
charges. 

A  rectum  partly  stuffed  with  lint,  and  containing 
three,  four,  or  more  ligatures  around  sensitive  parts,  is 
in  a  very  different  condition  from  one  which  contains 
no  foreign  substances,  and  the  wounds  of  which  have 
have  been  dressed  in  the  most  thoroughly  antiseptic 
way  possible  with  the  cautery  in  the  act  of  making 
them.  One  condition  may  be  no  safer  than  the  other, 
but  it  is  certainly  much  more  comfortable. 

No  dressing  of  any  sort  is  necessary  after  the 
clamp  operation.  If  the  patient  seems  to  be  doing 
well  and  complains  of   no  untoward   symptons,  the 


—  74  — 

parts  need  not  be  examined  for  ten  days,  and  all  that 
is  required  is  cleanliness  to  the  external  parts. 

I  usually  introduce  an  opium  and  belladonna  sup- 
pository at  the  time  of  the  operation,  and  it  is  seldom 
necessary  to  use  any  further  anodyne.  This  will  con- 
fine the  bowels  for  forty-eight  hours,  and  about  thirty- 
six  hours  after  the  operation — in  other  words,  at  night 
of  the  following  day — the  bowels  should  be  encour- 
aged to  act  by  a  slight  laxative,  either  a  pill  or  a 
saline.  A  single  dose  will  generally  be  sufficient,  and 
when  the  time  comes  for  the  bowels  to  move,  an 
enema  of  oil  should  be  thrown  up  the  retum  to  facili- 
tate the  passage.  In  this  way  an  almost  complete  clear- 
ing out  of  the  rectum  is  secured  on  the  second  day. 
The  patient  dreads  this  first  motion,  but  is  agreeably 
disappointed,  often  being  surprised  that  he  has  much 
less  pain  than  his  hemorrhoids  caused  him  in  each 
passage  before  they  were  removed. 

The  bowels  may  be  treated  in  this  way  after 
Allingham's  operation  with  great  advantage,  though 
his  rule  is  to  have  them  confined  for  a  week  or  more. 
By  the  one  method  a  comparatively,  and  sometimes 
positively,  painless  evacuation  is  gained  before  the 
rectum  has  become  loaded  with  solid  matter.  By  the 
other,  the  pain  which  is  sometimes  and  generally 
caused  needs  to  be  seen  and  felt  to  be  appreciated.  I 
have  left  my  bed  at  night,  roused  my  assistants,  driven 
to  an  adjacent  city,  given  ether,  and  unloaded  a  rec- 
tum, on  the  seventh  day  after  an  operation,  in  a  deli- 


—  75  — 

cate,  nervous  lady,  after  the  rectal  tenesums  had  re- 
duced her  to  a  condition  of  unmanageable  hysteria,  in 
spite  of  trained  nurse,  repeated  saline  cathartics,  and 
enemata  of  all  sorts;  and  one  experience  of  this  sort 
of  unnecessary  suffering  will  convert  almost  anybody 
to  the  other  plan. 

An  additional  advantage  of  thus  moving  the 
bowels  on  the  second  day  is  that  the  rectum  is  thus 
cleansed  of  all  blood  and  discharges,  and  that  no 
special  restrictions  need  be  placed  upon  the  patient's 
diet,  while  much  headache  and  general  malaise  which 
follow  the  constipation,  produced  by  the  daily  use  of 
opium,  are  avoided. 

I  have  recently  been  tending  a  case  where  much 
trouble  resulted  from  an  unintentional  departure  from 
this  rule.  The  usual  operation  was  done  with  a 
simultaneous  closure  of  a  lacerated  cervix  uteri,  and 
at  the  end  of  forty-eight  hours  the  usual  laxative  was 
given. 

I  was  told  on  the  following  day  that  it  had  acted 
nicely,  and  it  was  ordered  to  be  repeated  every  night 
for  the  following  week.  Each  day  the  patient  was  re- 
ported as  doing  well  in  this  regard,  though  once  or 
twice  it  was  necessary  to  give  two  pills  simultaneously 
when  the  bowels  seem.ed  to  be  acting  irregularly.  On 
the  tenth  day  the  patient  was  up  and  about,  preparing 
to  leave  the  city  for  her  home.  On  the  eleventh  she 
had  an  attack  of  intestinal  and  rectal  pain,  and  after  a 
great  deal  of   straining   and    suffering,    passed    a  very 


-  76  - 

voluminous  and  hard  passage,  with  considerable  blood. 
It  was  evident  that  the  bowels  had  not  been  effectively 
moved  since  the  operation,  and  the  result  of  her  efforts 
was  a  tearing  open  of  the  wounds,  and  a  further  con- 
finement to  the  house  for  nearly  three  weeks,  each 
movement  of  the  bowels  being  attended  with  some 
pain  and  bleeding. 

I  do  not  wish  to  convey  the  idea  that  no  pain  fol- 
lows this  operation,  but  I  can  honestly  say  that  many 
patients  have  less  pain  on  the  day  following  it  than 
they  have  suffered  daily  from  their  hemorrhoids  for 
years  before.  I  usually  expect  some  of  that  annoy- 
ing spasm  of  the  levator  which  no  stretching  of  the 
sphincter  can  prevent;  and  when  this  is  present  it  will 
begin  a  few  hours  after  the  ether,  and  may  last  for 
the  following  day  or  two;  but  it  is  not  generally  suf- 
ficient to  prevent  a  good  night's  sleep,  and  it  is  often 
so  slight  as  to  cause  no  comment  by  the  patient.  It  is 
very  exceptional  for  any  anodyne  to  be  necessary  even 
on  the  first  night  after  operating.  Even  this  spas- 
modic contraction  of  the  muscle  is  not  always  present. 

The  length  of  time  the  patient  is  confined  to  the 
house  of  course  varies.  They  are  generally  sitting  up 
on  the  second  day,  or  at  most  the  third  day,  and  walk- 
ing around  the  room  tending  to  their  own  wants,  the 
men  smoking  and  reading,  the  women  receiving  visits 
or  sewing:  and  one  of  the  details  about  which  the  phy- 
sician needs  to  be  most  strict  is  to  keep  the  patient 
quiet  in  the  house  until  the  healing  has  so  far  advanced 


—   77   — 

as  to  make  active  exercise  safe.  Many  of  my  own 
cases  come  from  a  considerable  distance  and  are  anxi- 
ous to  return  to  their  own  homes  as  soon  as  possible. 
I  usually  aim  to  secure  at  least  ten  days,  but  I  find 
they  are  very  apt  to  depart  at  the  end  of  a  week,  and 
occasionally  five  days  sees  them  on  their  journey.  I 
do  not  mean  that  this  should  be  encouraged  or  recom- 
mended, for  it  is  very  much  better  that  the  patient 
should  remain  quiescent  until  the  wounds  are  well  ad- 
vanced toward  cicatrization;  but  it  shows  better  than 
anything  else  the  general  condition  of  the  patient 
when  there  is  no  suffering  which  induces  him  to  wish 
to  stay  in  his  room. 

There  remains  very  little  to  be  said.  Within  the 
past  two  or  three  years  several  plastic  operations  have 
been  advised  and  practiced — operations  consisting  in  an 
elaborate  dissection  and  removal  of  the  hemorrhoidal 
tumors  and  subsequent  careful  suturing  of  the  wounds. 
These  have  seemed  to  me  such  very  long  ways  around 
to  reach  a  given  point  that  I  have  never  been  tempted 
to  try  them.  My  own  practice,  after  much  searching 
after  improvements,  has  reduced  itself  to  about  this: 
If  the  patient  wishes  to  be  relieved  but  is  unwilling  to 
be  cured,  I  try  to  relieve  him  by  medical  or  perhaps 
the  minor  surgical  methods  described.  If  he  desire  to 
be  cured,  and  I  deem  the  case  fit  for  cocaine,  carbolic 
acid,  etc.,  I  employ  them.  If  he  have  extensive  dis- 
ease, in  which  nothing  blit  radical  operation  is  indi- 
cated, and  he  refuses  to  submit  to  this,  I  have  found 


-  73  - 

it  better  to  abandon  the  case  than  to  do  what  I  do  not 
myself  believe  to  be  to  his  or  her  best  advantage. 
If,  under  the  same  circumstances,  the  patient  will  be 
wholly  guided  by  me,  I  prefer  the  clamp  to  all  other 
radical  measures,  as  being  less  painful,  and  giving  a 
quicker  recovery. 


PHYSICIANS' LEISURE  LIBRARY 

FOR    iSSGf 

NOW   READY  FOR   DELIVERY. 


Inhalers,  Inhalations  and  Inhal- 
ants ■—•Robinson. 

The  Use  of  Electricity  in  the  Re- 
moval of  Superfluous  Hair  and 
the  Treatment  of  Various  Fa- 
cial Blemishes.— Fox. 

New  Medications. -Dujardin-Eeau- 
meLz. 

Modern  Treatment  of  Ear  Dis- 
eases.—Sexton. 

Spinal  Irritation.— Hammond 

Modern  Treatment  of  Eczema. 

— Piffard. 


Antiseptic    Midwifery.-yarriprue^. 

On  the  Determination  of  the 
Necessity  for  Wearing  Glasses. 

— Ro'isa. 

Physiological,  Pathological  and 
Therapeutic  Effects  of  Com- 
pressed Air.— Smith 

Granular  Lids  and  Contagious 
Ophthalmia.— Mittendorf. 

Practical     Bacteriology.— Satter- 

thwaite. 

Pregnancy,  Parturition  and  the 
Puerperal  State  and  Their 
Complications.— ^lunde. 


FOR 

READY  FOR   DELIVERY 

Diagnosis  and  Treatment 
of  Haemorrhoids.— Kelsey.  Ready. 

Diseases  of  the  Heart. 

Vol.  I. — Hujardin-Beaumetz. 


Modern  Treatment  of  Di- 
arrhoea and  Dysentery. 
— Palmer. 

Diseases  of  the  Heart. 
Vol.  Ij.-Dujardin-Beaumetz 

Intestinal  Diseases  of 
Children.— Jacobi. 

Modern  Trea+ment  of 
Headaches.— Hamilton. 


July  1. 

Aug.  1. 

Aug.  15. 

Sept.  15. 

Nov.  1. 


1SS79 

AS  ANNOUNCED   BELOW. 
Modern  Treatment  of 
Pleurisy  and  Pneumonia. 

—Garland.  Not.  15. 

How  to  Use  the  Laryngo- 
scope.-By  an  eminent  Lar- 
yngologist.  Nov.  30. 

Diseases  of  the  Male 
Urethra  —Otis.  Dec.  1 

Disorders  of  Menstruation. 

— Jenks.  Dec.  15. 

The  Infectious  Diseases.— 

Liebermeister. 
In  2  vols.  Vol.  I,  Dec.  15. 

Vol.  II,  Dec.  30. 


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